Katharine Dexter McCormick and Stanley McCormick Memorial Professor in the School of Medicine

Psychiatry and Behavioral Sciences

Bio

Bio

Dr. Roberts serves as Chairman and the Katharine Dexter McCormick and Stanley McCormick Memorial Professor in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. She is an internationally recognized scholar in bioethics, psychiatry, medicine, and medical education. Over two decades, Dr. Roberts has received scientific, peer-reviewed funding from the National Institutes of Health, the Department of Energy, and private foundations to perform empirical studies of modern ethical issues in research, clinical care, and health policy, with a particular focus on vulnerable and special populations. Her work has led to advances in understanding of ethical aspects of physical and mental illness research, societal implications for genetic innovation, the role of stigma in health disparities, the impact of medical student and physician health issues, and optimal approaches to fostering professionalism in medicine.

Dr. Roberts has written hundreds of peer-reviewed articles and other scholarly works, and she has written or edited several books in the areas of professionalism and ethics in medicine, professional development for physicians, and clinical psychiatry. Dr. Roberts was recently appointed as the Editor-in-Chief, Books for the American Psychiatric Assocation. Dr. Roberts has been the Editor-in-Chief for the journal Academic Psychiatry since 2002 and serves as an editorial board member and peer reviewer for many scientific and education journals.

Dr. Roberts received the 2015 MacLean Center Prize recognizing her bioethics work. She was chosen to receive the Distinguished Psychiatrist award from the American Psychiatric Association in 2005 and 2010 and was recognized as the foremost leader in psychiatric education in the United States and Canada by the University of Toronto in 2008. Dr. Roberts has also received numerous awards for leadership, teaching, and science, including the Lifetime Achievement Award from the Association for Academic Psychiatry in 2010 and the Nancy C.A. Roeske, M.D., Certificate of Recognition for Excellence in Medical Student Education from the American Psychiatric Association.

Having received her Bachelor of Arts in History and Master of Arts in the Conceptual Foundations of Science from the University of Chicago, she then completed her medical degree and a fellowship in clinical medical ethics at the University of Chicago Pritzker School of Medicine. Dr. Roberts then performed her residency training in psychiatry at the University of New Mexico School of Medicine, where she also received additional clinical preparation in child and adolescent psychiatry. Dr. Roberts served on the faculty of the University of New Mexico School of Medicine for several years, performing evidence-based ethics research, administration, education, and clinical work in the specialized area of consultation-liaison psychiatry. While serving as Professor and Vice Chairman for her department, she established the University of New Mexico Institute for Ethics and was appointed the Jack and Donna Rust Professor of Biomedical Ethics prior to her departure in 2003. She then moved to the Medical College of Wisconsin, where for seven years she served as chairman of the Department of Psychiatry and the Charles E. Kubly Professor of Psychiatry and Behavioral Medicine. She came to Stanford University in 2010.

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Research & Scholarship

Current Research and Scholarly Interests

Dr. Roberts serves as Chairman and Katharine Dexter McCormick and Stanley McCormick Memorial Professor in the Department of Psychiatry and Behavioral Medicine at the Stanford University School of Medicine. She is a nationally recognized scholar and leader in ethics, psychiatry, medicine, and medical education. Dr. Roberts has performed numerous empirical studies of contemporary ethics issues in medicine and health policy and has been funded by the National Institutes of Health, the Department of Energy, the National Alliance of Schizophrenia and Depression, the Arnold P. Gold Foundation, and other private and public foundations.

In 2003, Dr. Roberts was appointed the Editor-in-Chief for Academic Psychiatry a journal focused on innovative education, mentorships, and leadership in academic psychiatry. Dr. Roberts has recently developed several books, including Concise Guide to Ethics in Mental Health Care, Professionalism and Ethics: Q & A Self-Study Guide, Handbook of Career Development in Academic Psychiatry and Behavioral Science, The Book of Ethics: Expert Guidance for Professionals Who Treat Addiction, and Clinical Psychiatry Essentials. She is presently working on International Handbook of Psychiatry: A Concise Guide for Medical Students, Residents, and Medical Practitioners.

Abstract

Collaborative writing in academic medicine gives rise to more richly informed scholarship, and yet challenging ethical issues surrounding authorship are commonly encountered. International guidelines on authorship help clarify whether individuals who have contributed to a completed scholarly work have been correctly included as authors, but these guidelines do not facilitate intentional and proactive authorship planning or decisions regarding authorship order.In this Commentary, the author presents a heuristic approach to help collaborators clarify, anticipate, and resolve practical and ethically important authorship issues as they engage in the process of developing manuscripts. As this approach illustrates, assignment of authorship should balance work effort and professional responsibility, reflecting the effort and intellectual contribution and the public accountability of the individuals who participate in the work. Using a heuristic approach for managing authorship issues prospectively can foster an ethical, collaborative writing process in which individuals are properly recognized for their contributions.

Abstract

The rapid rise of mobile health technologies, such as smartphone apps and wearable sensors, presents psychiatry with new tools of potential value in caring for patients. Novel diagnostic and therapeutic applications of these technologies have been developed in private industry and utilized in mental health, although these methods do not yet constitute standard of care. In this article, we provide an ethical perspective on the practical use of this novel modality by psychiatrists. We propose that in the present context of limited scientific research and regulatory oversight, mobile technologies should serve to enhance the psychiatrist-patient relationship, rather than replace it, to minimize potential clinical and ethical harm to vulnerable patients. We analyze areas of possible ethical tension between clinical practice and the consumer-driven mobile industry, and develop a decision-tree model for implementing ethical safeguards in practice, focused on managing risk to the therapeutic relationship, informed consent, confidentiality, and mutual alignment of treatment goals and expectations.

Abstract

This study assesses the prevalence of restless legs syndrome (RLS) using DSM-5 criteria and determines what is the most appropriate threshold for the frequency and duration of RLS symptoms.The Sleep-EVAL knowledge base system queried the interviewed subjects on life, sleeping habits, and health. Questions on sleep and mental and organic disorders (DSM-5, ICD-10) were also asked. A representative sample of 19,136 noninstitutionalized individuals older than 18 years living in the United States was interviewed through a cross-sectional telephone survey. The participation rate was 83.2%.The prevalence of the 4 leg symptoms describing RLS occurring at least 1 d/wk varied between 5.7% and 12.3%. When the frequency was set to at least 3 d/wk, the prevalence dropped and varied between 1.8% and 4.5% for the 4 leg symptoms. Higher frequency of leg symptoms was associated with greater distress and impairment with a marked increase at 3 d/wk. Symptoms were mostly chronic, lasting for more than 3 months in about 97% of the cases. The prevalence of RLS according to DSM-5 was 1.6% (95% confidence interval 1.4%-1.8%) when frequency was set at 3 d/wk. Stricter criteria for frequency of restless legs symptoms resulted in a reduction of prevalence of the disorder. The prevalence was further reduced when clinical impact was taken into consideration.In order to avoid inflation of case rates and to identify patients in whom treatment is truly warranted, using a more conservative threshold of 3 times or greater per week appears the most appropriate.

Abstract

Professional societies engage in activities with the aim of nurturing highly talented early career members of their field. Little is known about the value of honorary fellowship awards given annually by professional societies. Following up on the only known prior study of this topic, authors queried fellowship awardees in one psychiatric society to better understand the perceived value of honorary fellowships and other outcomes, such as subsequent involvement in professional societies.The authors queried former participants in the Laughlin and Psychiatry Resident-In-Training Examination® (PRITE®) Programs regarding their fellowship experiences and their subsequent involvement in The American College of Psychiatrists and other psychiatry membership organizations. The authors obtained frequency data and analyzed responses using t-tests and chi-squared tests. Associations between the outcomes and demographic characteristics such as age, gender, and fellowship type was tested.Responses were gathered from 143 individuals who had participated in the Laughlin Fellowship and 22 in the PRITE Fellowship. Respondents felt that that the fellowship experience had been helpful professionally. Laughlin fellows were older and more likely to have assumed a leadership role in professional organizations (60 % vs 36 %, p = 0.04). Laughlin fellows also more strongly endorsed professional recognition as a benefit at the time of receiving their award. Survey respondents reported increased participation in professional organizations and assumed leadership roles in The College and other professional organizations subsequent to the fellowship experience.On the whole, fellows were generally positive about their experiences. Many respondents became involved with The College subsequent to their fellowship, but a larger proportion became involved with other organizations, including in leadership roles. Professional societies with early career programs such as the Laughlin Fellowship and the PRITE Fellowship appear to identify and support future leaders as intended, but these leaders may engage more with other professional societies.

Abstract

Mental disorders account for considerable suffering and societal burden. Prospective alternative decision-makers may be engaged in helping make treatment decisions for those who live with serious mental disorders. Little is known about the ways in which alternative decision makers arrive at treatment recommendations and whether the perspectives of alternative decision makers and ill individuals are aligned.The authors queried community-dwelling individuals diagnosed with schizophrenia, anxiety, or mood disorders and their preferred alternative decision-makers on issues regarding treatment decisions and underlying ethically-salient perspectives using a written survey instrument. Complete data were obtained on 26 pairs (n = 52, total). Outcomes included perspectives on clinical decision-making and underlying values that may shape their life choices. Two-sided paired t-tests and graphical representations were used.We found that preferred alternative decision-makers overall accurately predicted the views of ill individuals with respect to the role of the individual and of family in treatment decision making. Preferred alternative decision-makers slightly overestimated autonomy-related perspectives. The personal views of ill individuals and preferred alternative decision-makers were aligned with respect to different physical and mental disorders, except in relation to alcohol and substance use where alternative decision-makers placed greater emphasis on autonomy. Alignment was also discovered on underlying life values, except the role of spirituality which was greater among alternative decision-makers.Preferred alternative decision-makers are an ethical safeguard to ensure the wellbeing and rights of seriously ill individuals. In this pilot study, preferred alternative decision makers were aligned with their ill family members concerning treatment-related decisions and underlying life values. Future research should continue to explore and clarify the views of ill individuals and alternative decision makers to determine the quality of this safeguard used in clinical settings.

Attunement and alignment of people with schizophrenia and their preferred alternative decision-makers: An exploratory pilot study comparing treatment and research decisionsJOURNAL OF PSYCHIATRIC RESEARCHRoberts, L. W., Kim, J. P.2015; 71: 70-77

Abstract

Because there are no formal reviews, the authors set out to identify and describe programs that serve female patients with major mental disorders by integrating mental health care with services in obstetrics and gynecology and to describe the pedagogical implications of those programs.The authors searched PubMed for all articles describing a program in which psychiatry was formally integrated with obstetric or gynecological services, other than standard consultation-liaison programs, in the care of patients with major mental disorders. The search terms used included interdisciplinary, interprofessional, integrated, collaborative care, psychiatry, and obstetrics-gynecology or psychosomatic obstetrics-gynecology.The authors found six distinct integrated programs. These included family planning clinics that were integrated into inpatient psychiatry services; inpatient and outpatient psychiatry services for pregnant mentally ill women in close collaboration with obstetric services; a day hospital for pregnant women with psychiatric disorders in an obstetric setting; an interdisciplinary training site providing care for predominantly depressed, low-income, and minority women; a primary care HIV service for women integrated with departments of obstetrics-gynecology and psychiatry; and an obstetrics-gynecology clinic-based collaborative depression care intervention for socially disadvantaged women. Residents' involvement was described in four of the programs.These innovative and integrated programs potentially enhance the care of vulnerable and culturally diverse women with major mental disorders. The authors discuss how these programs may contribute to the education of residents in psychiatry and obstetrics-gynecology.

Abstract

The objective of this study is to assess the attitudes of chairs of psychiatry departments, psychiatrists, and psychiatry trainees toward neuroscience education in residency programs and beyond in order to inform future neuroscience education approaches.This multi-stakeholder survey captured data on demographics, self-assessments of neuroscience knowledge, attitudes toward neuroscience education, preferences in learning modalities, and interests in specific neuroscience topics. In 2012, the authors distributed the surveys: by paper to 133 US psychiatry department chairs and electronically through the American Psychiatric Association to 3,563 of its members (1,000 psychiatrists and 2,563 trainees).The response rates for the chair, psychiatrist, and trainee surveys were 53, 9, and 18 %, respectively. A large majority of respondents agreed with the need for more neuroscience education in general and with respect to their own training. Most respondents believed that neuroscience will help destigmatize mental illness and begin producing new treatments or personalized medicines in 5-10 years. Only a small proportion of trainees and psychiatrists, however, reported a strong knowledge base in neuroscience. Respondents also reported broad enthusiasm for transdiagnostic topics in neuroscience (such as emotion regulation and attention/cognition) and description at the level of neural circuits.This study demonstrates the opportunity and enthusiasm for teaching more neuroscience in psychiatry among a broad range of stakeholder groups. A high level of interest was also found for transdiagnostic topics and approaches. We suggest that a transdiagnostic framework may be an effective way to deliver neuroscience education to the psychiatric community and illustrate this through a case example, drawing the similarity between this neuroscience approach and problem-based formulations familiar to clinicians.

Abstract

The authors explore the experiences of residents with respect to informal care related to personal health, including "curbside consultation," self-diagnosis, and self-prescription-self-care practices that run counter to ethical guidelines in medicine.Residents at one medical school completed a written survey regarding their personal health care practices, including their experiences in seeking or providing informal consultation, self-diagnosis, and self-prescribing. The authors obtained frequency data and analyzed responses via cross-tabulation. They used logistic regression models to assess the association of reported informal care practices and potential confounders, such as age, gender, and training program.One hundred and fifty-five residents volunteered (71 % response rate). Most respondents had sought health care formally (70 %), and more had sought informal care in the previous 12 months (80 %). Of those who had pursued informal care, 90 % endorsed having requested a physical exam, a laboratory test, or a medication prescription from an attending, resident, or medical student. Respondents (28 %) commonly endorsed prescribing medication for themselves. Most respondents (90 %) reported being approached for informal care at least once in the previous year, including 84 % who were approached for prescriptions and 22 % who were approached by attending physicians. Main reasons endorsed for informal care seeking related to busy schedules and to cost and confidentiality advantages. Psychiatry residents reported using both formal and informal channels for personal health care, and 31 % acknowledged prescribing medications for themselves.Informal care was a common practice among the residents in this study. Residents reported time constraints as the greatest influence on informal care seeking, rather than reasons found in previous studies related to cost and quality of care, protection of confidentiality, or prevention of embarrassment. The effects of informal care practices involving resident physicians warrant additional study.

Abstract

In this study, we used a strict definition of hypersomnia and tested if the association between overeating-hypersomnia remained positive and significant. Hypersomnia was present if the total sleep time was close to 10h per day or was at least 2h longer than in normothymic periods.Cross-sectional study using the adult general population of California and New York. The sample was composed of 6694 individuals aged between 18 and 96years. Participants were interviewed by telephone using the Sleep-EVAL system. The interviews included various sleep and health topics and the assessment of DSM-IV sleep and psychiatric disorders.The one-month prevalence of major depressive episode was 6.1%, including a one-month prevalence of atypical depression of 1.6%, in this sample. Atypical depression subjects had a greater number of depressive symptoms and a longer duration of the current depressive episode than the other depressive subjects. Depressive subjects with hypersomnia slept longer (8h, 29min) than the other depressive subjects (6h, 36min) and longer than the subjects "getting too much sleep" (6h, 48min). Furthermore, hypersomnia was not associated with overeating while "getting too much sleep" showed a positive association with overeating.Hypersomnia needs to be evaluated using a strict definition. Otherwise, it leads to an overestimation of this symptom in major depressive episode subjects and to a false association with overeating.

Abstract

Ethical controversy surrounds clinical research involving seriously ill participants. While many stakeholders have opinions, the extent to which protocol volunteers themselves see human research as ethically acceptable has not been documented. To address this gap of knowledge, authors sought to assess views of healthy and ill clinical research volunteers regarding the ethical acceptability of human studies involving individuals who are ill or are potentially vulnerable.Surveys and semi-structured interviews were used to query clinical research protocol participants and a comparison group of healthy individuals. A total of 179 respondents participated in this study: 150 in protocols (60 mentally ill, 43 physically ill, and 47 healthy clinical research protocol participants) and 29 healthy individuals not enrolled in protocols. Main outcome measures included responses regarding ethical acceptability of clinical research when it presents significant burdens and risks, involves people with serious mental and physical illness, or enrolls people with other potential vulnerabilities in the research situation.Respondents expressed decreasing levels of acceptance of participation in research that posed burdens of increasing severity. Participation in protocols with possibly life-threatening consequences was perceived as least acceptable (mean = 1.82, sd = 1.29). Research on serious illnesses, including HIV, cancer, schizophrenia, depression, and post-traumatic stress disorder, was seen as ethically acceptable across respondent groups (range of means = [4.0, 4.7]). Mentally ill volunteers expressed levels of ethical acceptability for physical illness research and mental illness research as acceptable and similar, while physically ill volunteers expressed greater ethical acceptability for physical illness research than for mental illness research. Mentally ill, physically ill, and healthy participants expressed neutral to favorable perspectives regarding the ethical acceptability of clinical research participation by potentially vulnerable subpopulations (difference in acceptability perceived by mentally ill - healthy = -0.04, CI [-0.46, 0.39]; physically ill - healthy = -0.13, CI [-0.62, -.36]).Clinical research volunteers and healthy clinical research-"naïve" individuals view studies involving ill people as ethically acceptable, and their responses reflect concern regarding research that poses considerable burdens and risks and research involving vulnerable subpopulations. Physically ill research volunteers may be more willing to see burdensome and risky research as acceptable. Mentally ill research volunteers and healthy individuals expressed similar perspectives in this study, helping to dispel a misconception that those with mental illness should be presumed to hold disparate views.

Abstract

The authors sought to compare investigators' predictions of clinical research participants' attitudes regarding ethically-important considerations in serious illness research with attitudes expressed by participants ("attunement"), to compare the personal attitudes of investigators and clinical research participants ("alignment"), and to explore the association between views expressed and covariates.The authors queried clinical research participants with either physical or mental illness (n=100) and faculty investigators conducting the clinical research protocols in which these participants were enrolled (n=77). Outcomes included attitudes regarding importance of medical research, attributes of seriously ill people in the research situation, and influences on enrollment decisions by seriously ill people. Generalized estimating equations and linear regression models were used.Investigators underestimated the importance of research about physical illness, mental illness, and healthy people to participants (βPI=0.59, 95% CI [0.36, 0.83]; βMI=0.60, 95% CI [0.27, 0.92]; βH=0.93, 95% CI [0.57, 1.29]). Investigators incorrectly predicted that participants would assess seriously ill people as more vulnerable in the research situation than participants did (β=-0.68, 95% CI [-1.11, -0.25]). Investigators and participants were aligned on the importance of illness research. Participants expressed greater agreement than investigators regarding the influences of ill individuals indicative of will and cognition in their enrollment decisions (β=0.69, 95% CI [0.25, 1.13]).Investigators are attuned to and aligned with research participants in many, but not all, respects. Investigators may bring a protective bias in their predictions of the vulnerabilities of ill volunteers.

Abstract

The purpose of this study is to assess the attitudes of psychiatry trainees toward neuroscience education in psychiatry residency and subsequent training in order to inform neuroscience education approaches in the future.This online survey was designed to capture demographic information, self-assessed neuroscience knowledge, attitudes toward neuroscience education, preferences in learning modalities, and interest in specific neuroscience topics. Volunteers were identified through the American Psychiatric Association, which invited 2,563 psychiatry trainees among their members.Four hundred thirty-six trainees completed the survey. Nearly all agreed that there is a need for more neuroscience education in psychiatry residency training (94 %) and that neuroscience education could help destigmatize mental illness (91 %). Nearly all (94 %) expressed interest in attending a 3-day course on neuroscience. Many neuroscience topics and modes of learning were viewed favorably by participants. Residents in their first 2 years of training expressed attitudes similar to those of more advanced residents and fellows. Some differences were found based on the level of interest in a future academic role.This web-based study demonstrates that psychiatry residents see neuroscience education as important in their training and worthy of greater attention. Our results suggest potential opportunities for advancing neuroscience education.

Abstract

To examine how occupational activities (work, school), separation from parents, environmental conditions, stressors ad social insertion affect on the prevalence of Major Depressive Disorder (MDD) and mental health care-seeking among young adults.Cross-sectional study conducted in two samples: 1) 19,136 subjective representative of the US non-institutionalized general population including 2082 18-26 y.o. subjects. 2) 2196 subjects representative of the students' population living on an university campus. Telephone interviews were realized using the Sleep-EVAL system to assess sleeping habits, general health, organic, sleep and mental disorders.One-month prevalence of depressed mood was similar between community and campus student groups (21.7% and 23.4%), and less common than for working (23.6%) and non-working (28.2%) young adults in the community. One-month MDD was found in 12.0% of non-working young people, compared with 6.6% of young workers, 3.2% of on-campus students and 4.1% of students in the general population (p

DSM-5 and the Five Missions Shouldered by Chairs of PsychiatryACADEMIC PSYCHIATRYRoberts, L. W.2014; 38 (1): 61-63

Abstract

The author provides a department chairman's perspective on the opportunities and challenges inherent in the DSM-5 transition. The author discusses these topics in relation to the missions of science, clinical innovation and service, education, community engagement, and leadership. To provide accurate information for their faculty, learners, and staff, chairs will need to provide venues for dialogue, minimize divisiveness, support departmental leaders to help with transition issues, and speak up for patients and the profession in the process.

Perceptions of African-American Health Professionals and Community Members in the Participation of Children and Pregnant Women in Genetic ResearchPUBLIC HEALTH GENOMICSNgui, E. M., Warner, T. D., Roberts, L. W.2014; 17 (1): 23-32

Abstract

As genetic research gains more prominence in society, ethical concerns and the need for safeguards in the participation of children and pregnant women have increased. This study examined the perspectives of African-American health professional and community members on genetic research involving children and pregnant women.We used a mixed-methods approach to collect and analyze survey data and qualitative data from focus groups of community members and structured interviews of health professionals.We found that community members had significantly more favorable attitudes toward participation of children and pregnant women in genetic research than health professionals. Health professionals did not differ significantly from community members in their perceived understanding of genetic research. Emergent themes included limited knowledge of genetic research and distinction of biomedical research and clinical care, ethical concerns about confidentiality and potential harm, and the need to protect children and pregnant women. Participants expressed high interest and favorable attitude towards genetic research, despite limited genetic knowledge and concerns of potential harm to children and pregnant women. Some participants felt that genetic research findings could help dispel stigma and reduce discrimination, especially in mental illness.Findings suggest that the recruitment of participants into genetic research should directly address privacy and benefit concerns, and limited knowledge of physical and mental illness genetic research. There is a critical need to invest and engage racial/ethnic communities early, provide education on genetics, mental illness, and translate and share research findings with these communities.

Abstract

Professionalism is one of the fundamental expectations and a core competency in residency education. Although programs use a variety of evaluative methods, little is known about residents' views of and preferences regarding various methods of assessment.The authors surveyed residents at seven psychiatry residency programs in the United States regarding their attitudes on professionalism, ethics preparation, and evaluation in psychiatry residency training. This report describes their views on methods of assessing professionalism.Residents strongly agreed that clinical supervision is an appropriate assessment method. Moreover, they rated clinical supervision more highly than oral examinations, short-answer questions, essays, and standardized patient interactions. Residents also strongly favored direct faculty observation of residents' interactions with actual patients and clinical team members.This study suggests that both direct faculty supervision and other clinically-based assessments are methods accepted by psychiatry residents. Future research on the validity and effectiveness of these modes of assessment is needed.

Abstract

Ethical guidelines suggest that, when enrolling patients with dementia in research, alterative decision makers (proxies) should base their decision on a "substituted judgment" of how the patient would have decided. If unable to make a substituted judgment, proxies are asked to decide on the basis of the patient's best interests. This mixed-methods study is the first to examine explicitly whether and to what degree proxies differentiate between these two approaches and what considerations influence their mode of decision making.Interview study regarding enrollment of relative in hypothetical clinical trial of an investigational drug for Alzheimer disease. Participants were randomized to respond to questions about one of four hypothetical clinical trials that differed by levels of described risk and potential benefit.Proxy decision makers (N = 40).Open-ended and rating-scaled items.Half of the proxies agreed with both of two rating-scaled items asking about different approaches to decision making-that is, agreeing that they would decide on the basis of how their relative would have decided and agreeing that they would decide on the basis of what they believed was in their relative's best interests. Narrative responses elaborated on themes within the following three major domains: Substituted judgment, best interests, and weighing substituted judgment and best interests. Substituted judgment was framed as honoring the patient's wishes and values. Best interests was described as a perceived duty to maintain quality of life and avoid burdens or risks. Weighing the two standards emerged as a challenging yet important, way of honoring wishes while maintaining quality of life. An unexpected theme was the attempt by alternative decision makers to discern their loved one's current versus premorbid research preferences.Tensions exist between abstract ethical principles regarding decision-making "standards" and their translation into research decisions.

Abstract

Investigators generally address the ethical dilemma of patients' decisional impairment in Alzheimer disease (AD) research by obtaining consent from alternative or surrogate decision makers ("proxies") as well as assent from patients. How these proxies conceptualize patient assent, or lack of objection, to participate may influence decisions made of the patients' behalf, but has been little studied. This report examines statements of proxies relevant to how they conceptualized assent and dissent to research.Surveys and in-depth interviews of proxies presented with hypothetical scenario related to enrolling relatives with AD in a clinical trial of an investigational drug for AD.Proxies (n = 25) for people with AD.Open-ended and rating-scaled items assessing perspectives on enrollment in research, influences on decision-making, and willingness to override a relative's preferences regarding research participation. Statements with relevance to assent or dissent were coded.Proxies described looking for consistent behavioral or verbal indications of assent versus objection when trying to determine patients' preferences. However, proxies sometimes expressed willingness to override patients' desires in favor of patients' presumed best interests. The amnestic nature of the disorder led some proxies to justify overriding temporary dissent or discomfort in the interest of promoting patients' values. Patients' dependence on their caregivers for decision-making, and caregivers' awareness of their ability to persuade their relatives, also emerged in descriptions of the decision-making process.Proxies' statements regarding a hypothetical research enrollment decision revealed several themes with implications for the concepts of assent and dissent. Proxies may persuade or influence patients to promote the patient's best interests or values. Further work, particularly examining actual decision-making, is warranted to determine how best to operationalize the concepts of assent and dissent in the context of research involving decisionally impaired adults.

Abstract

The authors identify and describe strategies for success in writing for publication, including how to choose an educational research topic, define the question and choose the correct design, know the anatomy of a research paper, write each of the sections, optimize the writing before publication, choose a journal, and respond to editors and reviewers. The research question should be focused, modest, and achievable given the constraints of the setting, significant, and appropriately imbedded in the available literature. The choice of methods is determined by the nature of the educational research question and should conform to ethical standards. Specific strategies for writing include starting where it is easiest to do so, spontaneously and uncritically writing the first paragraphs through, minimizing external impediments to the work, and knowing how each section of a manuscript is routinely structured. All papers require a number of revisions with careful attention to accuracy and detail as well as to specific requirements of the target journal before submission. Authors should respond positively, not defensively, and in detail to all of the editor's and reviewers' suggestions for revision. Writing for success is therefore a disciplined and systematic process following prescribed steps, which, although hard work, is rewarding.

Alternative Decision-Makers' Perspectives on Assent and Dissent for Dementia Research.The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry2012

Abstract

OBJECTIVES:: Investigators generally address the ethical dilemma of patients' decisional impairment in Alzheimer disease (AD) research by obtaining consent from alternative or surrogate decision makers ("proxies") as well as assent from patients. How these proxies conceptualize patient assent, or lack of objection, to participate may influence decisions made of the patients' behalf, but has been little studied. This report examines statements of proxies relevant to how they conceptualized assent and dissent to research. DESIGN:: Surveys and in-depth interviews of proxies presented with hypothetical scenario related to enrolling relatives with AD in a clinical trial of an investigational drug for AD. PARTICIPANTS:: Proxies (n = 25) for people with AD. MEASUREMENTS:: Open-ended and rating-scaled items assessing perspectives on enrollment in research, influences on decision-making, and willingness to override a relative's preferences regarding research participation. Statements with relevance to assent or dissent were coded. RESULTS:: Proxies described looking for consistent behavioral or verbal indications of assent versus objection when trying to determine patients' preferences. However, proxies sometimes expressed willingness to override patients' desires in favor of patients' presumed best interests. The amnestic nature of the disorder led some proxies to justify overriding temporary dissent or discomfort in the interest of promoting patients' values. Patients' dependence on their caregivers for decision-making, and caregivers' awareness of their ability to persuade their relatives, also emerged in descriptions of the decision-making process. CONCLUSIONS:: Proxies' statements regarding a hypothetical research enrollment decision revealed several themes with implications for the concepts of assent and dissent. Proxies may persuade or influence patients to promote the patient's best interests or values. Further work, particularly examining actual decision-making, is warranted to determine how best to operationalize the concepts of assent and dissent in the context of research involving decisionally impaired adults.

"Thinking About It for Somebody Else": Alzheimer's Disease Research and Proxy Decision Makers' Translation of Ethical Principles Into Practice.The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry2012

Abstract

OBJECTIVES:: Ethical guidelines suggest that, when enrolling patients with dementia in research, alterative decision makers (proxies) should base their decision on a "substituted judgment" of how the patient would have decided. If unable to make a substituted judgment, proxies are asked to decide on the basis of the patient's best interests. This mixed-methods study is the first to examine explicitly whether and to what degree proxies differentiate between these two approaches and what considerations influence their mode of decision making. DESIGN:: Interview study regarding enrollment of relative in hypothetical clinical trial of an investigational drug for Alzheimer disease. Participants were randomized to respond to questions about one of four hypothetical clinical trials that differed by levels of described risk and potential benefit. PARTICIPANTS:: Proxy decision makers (N = 40). MEASUREMENTS:: Open-ended and rating-scaled items. RESULTS:: Half of the proxies agreed with both of two rating-scaled items asking about different approaches to decision making-that is, agreeing that they would decide on the basis of how their relative would have decided and agreeing that they would decide on the basis of what they believed was in their relative's best interests. Narrative responses elaborated on themes within the following three major domains: Substituted judgment, best interests, and weighing substituted judgment and best interests. Substituted judgment was framed as honoring the patient's wishes and values. Best interests was described as a perceived duty to maintain quality of life and avoid burdens or risks. Weighing the two standards emerged as a challenging yet important, way of honoring wishes while maintaining quality of life. An unexpected theme was the attempt by alternative decision makers to discern their loved one's current versus premorbid research preferences. CONCLUSIONS:: Tensions exist between abstract ethical principles regarding decision-making "standards" and their translation into research decisions.

Abstract

Because of the importance of sexual history-taking, the authors attempted to identify all randomized controlled trials on teaching this topic and reviewed the methods used for teaching and the efficacy of the educational interventions.From June to November 2010, the authors searched the published English-language literature indexed in PubMed, PsycINFO, and SCOPUS, using the key terms sexual history-taking, teaching, medical students, residents, sexual health, sexually transmitted infections, HIV, and AIDS. The authors selected and critically appraised randomized controlled trials and controlled nonrandomized trials of educational programs designed to enhance sexual history-taking skills.Of 11 trials identified, 7 included medical students, 2 included residents, 1 involved community-based physicians, and 1 involved attendings, fellows, and residents. The educational interventions and outcome measures were heterogeneous, and the quality of study methodologies varied widely. The authors judged only 1 study to be of very high quality, although 8 studies explicitly mentioned at least one of the following: group differences at baseline, blinding, follow-up, and validated measurement tools. In the highest-quality study, primary care physicians who were mailed educational materials and received an unannounced instructor visit performed better in risk assessment and counseling than two comparison groups. Evidence also supported interactive workshops over didactic presentations.The dearth of high-quality controlled studies hampers the development of sexual history-taking curricula for medical students and residents. The available literature supports formal opportunities to directly practice and receive feedback on interviewing skills. More rigorous research on sexual history-taking education is needed.

Abstract

Surrogate (proxy) decision makers must make research decisions for people with dementia who lack decision-making capacity. Proxies' decision-making processes are minimally understood. We randomly assigned 82 proxies of AD patients to informed consent for one of three hypothetical protocols with differing levels of risk and benefit. Proxies answered questions about potential benefits of the described research to the patient and society, as well as about whether they would enroll their relative and why or why not. Proxies interested in enrolling their relative cited the potential for direct benefit to their relative, altruism, and trust in researchers. Those declining cited risks, inconvenience, and stage of illness. Proxies weighed numerous factors, incorporating both substituted judgment and best interests standards in their decision-making processes. Although further empirical work is needed to understand the influences on and adequacy of proxies' decision making regarding research, these findings can help inform policy regarding surrogate consent.

Abstract

Medical students experience a range of mental and physical illnesses during training and may encounter significant barriers in seeking health care. Little is known about the issues surrounding the dual role as both learner and patient when a medical student seeks care at his or her training institution.A confidential survey examining medical students' health care needs, practices, and concerns was administered at 9 US medical schools. One part of the survey focused on responses to 4 medical student-patient vignettes. The vignettes systematically varied preexisting student vs preexisting patient status before assuming a medical student-patient role, and the vignettes also varied illness situations that were more vs less stigmatizing. Responses were analyzed using χ(2) and multivariate analysis of variance tests.A total of 1027 students participated. We found that students were more likely to accept the dual role as medical student-patient in vignettes depicting a preexisting patient role than a preexisting student role. Students sought to avoid the dual role as student-patient in the context of stigmatizing health concerns. Women students were more likely than men to reject the dual role in all cases.Medical students appear to be sensitive to the conflicts that may be associated with the dual role as both medical student and patient when seeking care at their training institution. Our data suggest the importance of substantive efforts to promote the health, interests, and well-being of medical student-patients.

Abstract

Compassion is an attribute central to professionalism and modern clinical care, yet little is known about how compassion is acquired and preserved in medical training. We sought to understand whether personal illness experiences are thought by residents to foster compassion.The authors surveyed 155 (71% response rate) second- and third-year residents at the University of New Mexico School of Medicine regarding their views of the relationship of personal life experience with illness to compassion and empathy for patients.Residents believe that experience with personal health issues enhances physician compassion for patients. Residents who report more personal health concerns, such as physical or mental health problems and family health problems, endorse the connection between direct experience with illness and empathy.Health care trainees' own illness experiences may increase compassionate patient care practices and foster empathy.

Abstract

The authors assess the perspectives of psychiatry residents about the goals of receiving education in professionalism and ethics, how topics should be taught, and on what ethical principles the curriculum should be based.A written survey was sent to psychiatry residents (N=249) at seven U.S. residency programs in Spring 2005. The survey was based on an instrument originally developed at the University of New Mexico, consisting of 149 questions in 10 content domains, with 6 questions regarding ethics experiences during training and 5 demographic questions.A total of 151 psychiatry residents (61%) returned usable responses to our survey. Residents reported receiving a moderate amount of ethics training during medical school (mean: 5.20; scale: 1: None to 9: Very Much) and some ethics training during residency (mean: 4.60). Residents endorsed moderate to moderately-strong agreement with all 11 goals of medical education in professionalism and ethics (means: 5.29 to 7.49; scale: 1: Strongly Disagree to 9: Strongly Agree). Respondents were more likely to endorse the value of clinically- and expert-oriented learning methods over web-based educational approaches.U.S. psychiatry residents endorse a range of goals for education in professionalism and ethics. At the same time, they prefer that these topics be taught in clinically relevant ways and through expert instruction. The value of web-based approaches warrants further investigation.

Abstract

To describe community-engaged research (CEnR) and how it may improve the quality of a research study while addressing ethical concerns that communities may have with mental health and substance abuse research. This article includes a review of the literature as well as recommendations from an expert panel convened with funding from the US National Institute of Mental Health.CEnR represents a broad spectrum of practices, including representation on institutional ethics committees, attitude research with individuals from the study population, engaging community advisory boards, forming research partnerships with community organizations, and including community members as co-investigators.CEnR poses some challenges; for example, it requires funding and training for researchers and community members. However, it offers many benefits to researchers and communities, and some form of CEnR is appropriate and feasible in nearly every study involving human participants.

Abstract

The authors examined psychiatric residents' perceived needs for education in informed consent, principles of ethics and professionalism, and treating vulnerable populations.A written survey was distributed to psychiatric residents (N=249) at seven U.S. residency programs in 2005. The survey contained 149 questions in 10 content domains, 6 questions regarding personal ethics experiences during training, and 5 demographic questions. Here, the authors report responses to items regarding informed consent, professional principles, and care of vulnerable populations.A total of 151 psychiatric residents responded to the survey (61% overall response rate). On a scale of 1: Much Less, to 5: Same, to 9: Much More Education Desired, psychiatric residents indicated that 9 topics relating to informed consent, 10 issues surrounding professional principles, and 25 topics relating to care of vulnerable populations should receive more educational attention than currently provided. No topics were rated as needing less education. Higher ratings of the need for additional educational attention were associated with more reported ethical conflicts encountered during training.Psychiatric residents at seven diverse U.S. training programs expressed the need for greater educational attention to issues around informed consent, ethical and professional principles, and treating vulnerable populations. These findings reflect the ongoing need for educators to devote curricular attention to these areas so that trainees can incorporate such knowledge effectively into their daily clinical practice in an always-complex, highly fragmented medical care environment.

Abstract

Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers' knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains.Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, "What are the 3 things you wish someone would have told you about delivering health care in rural areas?" were thematically coded.Emergent themes coalesced into 3 overarching themes addressing practice-related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner.Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services, and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.

Abstract

Pharmacogenetic testing for polymorphisms affecting drug response and metabolism is now clinically available, and its use in psychiatry is expected to become more widespread. Currently, few clinical and ethical standards exist for the use of these new tests. As a step toward building consensus about testing, we assessed the attitudes and practices of psychiatrists at 3 academic departments of psychiatry where pharmacogenetic testing is clinically available. We hypothesized that testing would be used primarily in treatment-resistant illness and that clinicians would believe such tests carried little risk.Residents and faculty at 3 departments of psychiatry considered to be "early adopters" of pharmacogenetic testing were invited during the academic year 2006-2007 to complete an Internet-based survey, including questions regarding clinical practices and opinions about testing utility, risks, and necessary safeguards.The 75 respondents had ordered pharmacogenetic testing a mean of 20.86 times in the previous 12 months. Testing was judged most useful in cases of treatment-resistant depression and medication intolerance. There was a lack of consensus about the risks of testing, particularly the risk of secondary information about disease susceptibility. Respondents endorsed the use of several safeguards, including confidentiality, pretest and posttest counseling, and informed consent, but consensus about other safeguards was lacking. Women and those who had not ordered testing in the prior year were more concerned about risks and need for safeguards than were men and those who had recently ordered testing.Physicians at early adopting departments of psychiatry endorsed the clinical utility of pharmacogenetic testing and the use of some patient safeguards, but showed a lack of consensus about other safeguards and risks.

Abstract

As researchers make progress in understanding genetic aspects of mental illness and its treatment, psychiatrists will increasingly need to understand and interpret genetic information specific to psychiatric disorders. Little is known about the extent to which residency programs are preparing psychiatrists for this new role. This study was designed to explore the current state of genetics education in psychiatric residency.U.S. psychiatric residency educators and residents were invited to participate in an Internet-based survey.Out of 509 educators and at least 207 residents contacted, 100 educators and 135 residents from 55 geographically dispersed U.S. psychiatry training programs in diverse settings responded to the survey. Participants rated genetics as somewhat important as a curricular topic but less important than other subjects. Nearly half of the educators reported that their program had few or no faculty with adequate expertise in teaching this subject. Most residents routinely obtained family psychiatric histories when evaluating patients, but most did not feel competent to order and interpret genetic tests or to interpret papers on psychiatric genetics.This study presents a sobering picture of the state of genetics education in psychiatric residency training. Potential obstacles to improving genetics education include perceptions of the relative importance of genetics in comparison with other topics and a lack of faculty with appropriate expertise.

Abstract

The global burden of neuropsychiatry diseases and related mental health conditions is enormous, underappreciated and under resourced, particularly in the developing nations. The absence of adequate and quality mental health infrastructure and workforce is increasingly recognized. The ethical implications of inequalities in mental health for people and nations are profound and must be addressed in efforts to fulfil key bioethics principles of medicine and public health: respect for individuals, justice, beneficence, and non-malfeasance. Stigma and discrimination against people living with mental disorders affects their education, employment, access to care and hampers their capacity to contribute to society. Mental health well-being is closely associated to several Millennium Development Goals and economic development sectors including education, labour force participation, and productivity. Limited access to mental health care increases patient and family suffering. Unmet mental health needs have a negative effect on poverty reduction initiatives and economic development. Untreated mental conditions contribute to economic loss because they increase school and work absenteeism and dropout rates, healthcare expenditure, and unemployment. Addressing unmet mental health needs will require development of better mental health infrastructure and workforce and overall integration of mental and physical health services with primary care, especially in the developing nations.

Abstract

Despite the acknowledged importance of ethics education in medical school, little empirical work has been done to assess the needs and preferences of medical students regarding ethics curricula.Eighty-three medical students at the University of New Mexico participated in a self-administered written survey including 41 scaled questions regarding attitudes, needs, and preferences toward medical ethics and ethics education.Students reported strong personal interest in learning more about ethics in clinical medicine and research. They most strongly endorsed as valid objectives of ethics education the goals of helping professionals "better recognize ethical issues and clarify values-laden choices," "improve patient care and clinical decision-making," and "improve ethical practices in clinical research." Participants strongly agreed that "professional attitudes and values are an appropriate focus for medical education" and also expressed strong interest in learning more about specific ethical topics and learning methods. Women more strongly endorsed interest in additional ethics education and a preference for increased ethics education than men. Preclinical participants expressed a greater desire for additional training on all ethics topics than clinical students.The medical students surveyed strongly affirmed ethics education in medical school and expressed clear preferences for curricular topics and teaching methods.

Abstract

Whether and under what circumstances medical residents seek personal health care is a growing concern that has important implications for medical education and patient welfare, but has not been thoroughly investigated. Barriers to obtaining care have been previously documented, but very little empirical work has focused on trainees who seek health care at their home institution.A self-report survey on special issues in personal health care of residents was created and distributed at the University of New Mexico School of Medicine in 2001. The authors report findings regarding stigma, fear of jeopardy to training status, and attitudes toward seeking self-care for residents in dual roles as patients and trainees.Residents (N=155) rated their concerns regarding stigma and jeopardy to training status and the likelihood of seeking care at their training institution for six vignettes. The vignettes were paired to make comparisons between attending or supervisor as treating physician and between clinical scenarios. Alcohol abuse, nausea and diarrhea, panic attacks, and pregnancy were the most highly stigmatizing to residents; diabetes and hypertension were the least. Differences were also found for gender and specialty.Residents' perceived stigma for clinical situations was an influential factor, strongly affecting concern about jeopardizing training status and likelihood of avoiding care at their home institution.

Abstract

Awareness of the privileges and limits of one's role as physician, as well as recognition and respect for the patient as a human being, are central to ethical medical practice. The authors were particularly interested in examining the attitudes and perceived needs of psychiatric residents toward education on professional boundaries and relationships given the heightened current focus on professionalism and ethics.Residents from six psychiatric residencies provided views on professionalism and ethics education on a survey encompassing 10 domains of professionalism. The authors focus on residents' perceived need for education on boundaries in the psychiatrist-patient relationship and in peer-peer and supervisor-trainee interactions.Respondents (N=134) felt that nine relationship and boundary issues arising during training should receive more education: being asked to work with inadequate supervision, resolving conflicts between attendings and trainees, resident health care, adequately caring for patients while adhering to work-hour guidelines, performing work beyond one's competence, mistreatment of residents, sexual/romantic relationships between faculty and trainees, mistreatment of medical students, and sexual/romantic relationships between residents and medical students (p<0.05 in all cases). In addition, 15 relationship and boundary issues arising during clinical practice were felt to warrant more education: responding to impaired colleagues, coping with mistakes in clinical care, reporting mistakes, balancing personal and professional life, resolving conflicts, writing prescriptions for friends or family, allocation of health care resources, providing medical advice to friends and family, physicians' social responsibilities, interacting with families, medicine as a profession, gender bias, being asked to falsify clinical information, accepting gifts from patients, and personal relationships with patients (p<0.05 in all cases).The authors found a perceived need for more education for psychiatric residents for the majority of topics pertaining to boundaries and relationships. Residents who reported encountering ethical dilemmas more frequently wanted more education on these topics.

Abstract

Military psychiatrists are faced with multiple, difficult questions that shape the context for ethical patient care. These questions are difficult to answer and future efforts, including policy and evidence-based treatment practices, should aim at reducing the ambiguity faced by military psychiatrists. New research should focus on issues as diverse as optimal approaches to informed consent, evidence-derived approaches to protecting confidentiality, outcomes of care for individuals in widely varying military roles, and medication use in the field. Training for mental health care providers who deal with military patients should be provided not only in military graduate medical education but also in job-specific courses and in ethics. This should include specific training for personnel who will be dealing with specific populations, such as the US Army's current "Dealing with Detainee course" and the Army Medical Department's "Combat Operational Stress Course" for deploying military psychiatrists and psychologists.

Abstract

Ethical dilemmas are found throughout the daily work of C-L psychiatrists. Unfortunately, most psychiatrists have no more training in ethics than their nonpsychiatric colleagues. Psychiatric consults spurred by ethical dilemmas can provoke anxiety in psychiatrists and leave anxious colleagues without the clear recommendations they seek. C-L psychiatrists, and probably all psychiatrists, need more training in clinical ethics. C-L psychiatrists do not need to become clinical ethicists, but competence in handling the ethical issues most commonly seen in C-L work is needed. The 2008 ABPN guidelines for specialists in psychosomatic medicine mention specific ethics topics important in C-L work, and ways of attaining competence in these areas have been discussed in the C-L literature. The four cases discussed here illustrate the high level of complexity often seen in situations in which ethical dilemmas arise in C-L psychiatry. Given the sometimes furious pace of hospital work, it can be easy for C-L psychiatrists to be seduced by the idea of the quick, focused consult that simply responds to a simple question with a simple answer. Because cases involving ethical dilemmas often involve multiple stakeholders, each with his or her own set of concerns, a brief consult focused only on the patient often leads to errors of omission. A wider approach, such as that suggested by the Four Topics Method, is needed to successfully negotiate ethical dilemmas. Busy C-L psychiatry services may struggle at first to find the time to do the type of global evaluations discussed here, but increasing familiarity with approaches such as the Four Topics Method should lead to quicker ways of gathering and processing the needed information.

Ethics in Psychotherapy: A Focus on Professional Boundaries and Confidentiality PracticesPSYCHIATRIC CLINICS OF NORTH AMERICAJain, S., Roberts, L. W.2009; 32 (2): 299-?

Abstract

The practice of psychotherapy gives rise to many ethical dilemmas. In this article we offered a "primer" on the most commonly cited ethical concerns in psychotherapy related to professionalism and therapeutic boundaries and confidentiality. There is no single answer to the varied and complex ethical issues that therapists may encounter in their treatment of patients. Such dilemmas are dynamic, nuanced, complex, and highly context dependent. Although professional codes offer guidance on optimal standards of conduct, they do not always offer clear answers; hence, therapists need to be able to critically evaluate and interpret such codes in relation to their daily practice. The contemporary therapist continues to face new dilemmas in an ever-evolving and dynamic twenty-first-century practice environment. Ethical therapists serve the well-being of their patients above all other interests or commitments. Therapists who are attentive to the professional obligations they possess can adopt several strategies to increase their ethical competence, including constantly evaluating their own attitudes and behaviors in addition to those of their patients, engaging in dialog and developing expertise in relation to ethics issues, having a solid grasp of relevant professional codes of conduct, and demonstrating an openness to consultation with peers and exposure of their work to peer review.

Abstract

Evidence-based medicine and the professional virtues of integrity, compassion, self-effacement, and self-sacrifice constitute the cornerstones of an ethics of psychiatric education. As informed by the pioneering work of John Gregory, psychiatric educators must promote evidence-based and ethically justified behaviors in learners and practicing physicians through example and by formal teaching. These processes together will enable patients to trust the competence of psychiatrists and that psychiatrists will serve the interests of patients first.

Abstract

Storing tissue samples for future genetic testing raises practical and ethical issues regarding informed consent and confidentiality. Employed adults' views on this are uniquely valuable but have been little studied.This study surveyed 570 employees at a U.S. defense laboratory and an academic medical center regarding their willingness to have tissue stored for future genetic testing, interest in receiving results of future testing and being contacted for consent for future testing, and acceptability of various tissue-storage options.Respondents were somewhat interested in providing samples and significantly less interested in providing traceable samples than untraceable samples. Workers with concerns about having a genetic illness were more interested in providing tissue for future testing. Most participants expressed strong desire to be asked before future genotyping and to receive those test results. Respondents preferred that tissue samples be stored with their doctor, local medical facility, or local research university rather than with their employer, a government agency, or an insurance company.Employed adults valued future genetic testing as being important to their well-being and strongly preferred reconsenting for future use of stored tissue. These data provide a baseline to measure potential changes in workers' attitudes since the passage of the U.S. Genetic Information Nondiscrimination Act in 2008.

Abstract

The authors sought to understand the health issues and care-seeking practices reported by residents and explored the extent to which fear of academic jeopardy, stigma, and being the subject of discussion by colleagues may affect residents' care-seeking.Residents at the University of New Mexico Health Sciences Center were surveyed in 2000-2001 regarding avoidance or postponement of obtaining necessary health care, responses of others to absences, and perceptions of jeopardy to training status if a supervisor learned of a specific condition. Responses were analyzed via repeated-measures MANOVA.Of 217 surveys, 155 were returned (71% response rate). Concerns with mental health, pain, minor infections, or relationship, sleep-related, fatigue, or gynecological/urological problems were expressed by 26% to 43% of residents. Concerns of potential jeopardy if a director or supervisor learned about personal health issues were strongest for problems with drugs/alcohol, moderately high for HIV, and moderate for mental health, eating-related problems, cancer, and STDs. Residents had sometimes avoided seeking care, and 18% had often avoided or delayed care-seeking; women delayed or avoided care more often than men. More frequent avoidance of seeking care was associated with poorer self-rated mental and physical health and greater health concerns.Residents at times postpone or avoid seeking care. Time and scheduling difficulties influence the ability to obtain care. Perceptions of potential academic jeopardy, stigma, and reactions of colleagues may affect residents' attitudes and care-seeking. Further inquiry is essential to understand how extensively these factors may influence the well-being of residents.

Abstract

Community-based participatory research (CBPR) focuses on specific community needs, and produces results that directly address those needs. Although conducting ethical CBPR is critical to its success, few academic programs include this training in their curricula. This paper describes the development and evaluation of an online training course designed to increase the use of CBPR in mental health disciplines. Developed using a participatory approach involving a community of experts, this course challenges traditional research by introducing a collaborative process meant to encourage increased participation by special populations, and narrow the parity gap in effective mental health treatment and services delivery.

Abstract

Fostering the therapeutic alliance, safeguarding confidentiality, gaining informed consent, and enhancing treatment adherence are critical aspects of patient care. We examined whether multidisciplinary health care providers perceive additional training on these areas as helpful in their work with patients from different ethnic backgrounds than the provider. Data are drawn from a National Institute on Drug Abuse-funded survey of 1555 providers in 8 disciplines in New Mexico and Alaska. Clinicians viewed additional training as moderately helpful for ensuring treatment adherence, establishing the therapeutic alliance, safeguarding confidentiality, and engaging in informed consent processes, in that order. Women were more receptive than men to additional training. Modest differences were detected between behavioral and physical health providers and between minority and majority providers. Implications of providers' only modest interest in such training are discussed.

Abstract

To summarize important recent contributions to the literature on the subject of ethics in psychiatric research.Current literature reflects an expansion in the range of psychiatric research on ethics topics. Articles continue to appear on core ethics subjects such as informed consent, but many recent contributions focus on diverse issues such as third-party privacy, the ethics of Internet-based research, revisiting the wisdom of imposing medical ethics requirements on observational research, and psychiatric research ethics as applied to special populations such as children or older persons.Psychiatric research is critical for the elucidation, prevention, and treatment of mental diseases. Increased attention and novel approaches taken to obtain informed consent, correcting therapeutic misconception, and guarding privacy will advance the research enterprise and continue to ensure that the subjective experiences of participants in psychiatric research remain positive.

Abstract

This study examines attitudes of Mexican female immigrants to Albuquerque, New Mexico, regarding barriers to health care access in the United States and Mexico for stigmatizing and non-stigmatizing illnesses and moderating effects of social support. Native Spanish speakers conducted three focus groups (in Spanish) lasting two hours with seven to eight participants. Focus groups were transcribed, translated, and coded. Frequency data were calculated by number of times concepts or themes were raised. Comparisons of barriers to health care access were made between U.S. and Mexican cultures. The majority (86%) of comments on barriers for non-stigmatizing illnesses implicated U.S. culture; the majority (90%) for stigmatizing illnesses implicated Mexican culture. Social support for stigmatizing illnesses was discussed. Participants discussed important issues of health care access for stigmatizing illnesses that may have implications for this population's health status. Greater attention should be paid to stigma and social support in future empirical studies.

Abstract

A probability sample of U.S. psychiatrists (n = 93) was invited to complete a mail survey regarding the likely impact of genetic testing on psychiatry; the clinical utility of pharmacogenetic, diagnostic, and susceptibility genetic testing; and 14 proposed ethical and legal safeguards for clinical genetic testing.Forty-five psychiatrists participated in the survey (response rate = 48%). The majority (80% and 60%, respectively) believed that genetic testing would benefit many psychiatric patients and would dramatically change the way psychiatry is practiced. Many psychiatrists (73-85%) also stated that pharmacogenetic, diagnostic, and susceptibility tests for common psychiatric disorders would be somewhat useful or extremely useful in the clinical setting. Nearly all (98-100%) believed that psychiatrists should obtain informed consent before genetic testing, should keep test results confidential, should provide pre- and posttest counseling, and should demonstrate competence in interpreting test results. Nearly all (96-100%) supported laws and regulations to prevent discrimination based on genetic test results and to protect consumers from misleading advertisements for testing. Ninety-one percent endorsed restrictions on the sale of genetic tests directly to consumers.This probability sample of U.S. psychiatrists expressed a strongly positive view of genetic testing in psychiatry, while voicing nearly unanimous support for seven ethical and legal safeguards.

Abstract

Barriers to ethical and effective health care in rural communities have been well-documented; however, less is known about strategies rural providers use to overcome such barriers. This study compared adaptations by rural and urban health care providers. Physical and behavioral health care providers were randomly selected from licensure lists for eight groups to complete a survey; 1,546 (52%) responded. Replies indicated that health care providers from small rural and rural communities were more likely to integrate community resources, individualize treatment recommendations, safeguard client confidentiality, seek out additional expertise, and adjust treatment styles than were providers from small urban and urban communities. Behavioral health care providers were more likely than physical health care providers to integrate community resources, individualize treatment recommendations, safeguard client confidentiality, and adjust their treatment styles; physical health care providers were more likely than behavioral health care providers to make attempts or have options to seek out additional expertise.

Abstract

Psychiatric research on children and adolescents is ethically justified by the need to reduce the burden that mental illnesses place on young people, their families, and society. Such research must be conducted with careful attention to the ethical principles of beneficence, justice, and respect for persons. Child and adolescent psychiatrists who collaborate on research trials or advise patients and families about research participation should consider nine domains when evaluating the ethical acceptability of particular protocols. These domains include scientific merit and design; expertise, commitment, and integrity; risks and benefits; confidentiality; participant selection and recruitment; informed consent and decisional capacity; incentives; institution and peer/professional review; and data presentation. Special ethical issues in child and adolescent psychiatry research concern the use of randomized, controlled treatment trials; the informed consent process for research involving adolescents; the therapeutic misconception; and conflicts of interest in physician referrals.

Psychiatrists' attitudes, knowledge, and experience regarding genetics: a preliminary study.Genetics in medicine : official journal of the American College of Medical Genetics2008

Abstract

PURPOSE:: This study is the first survey of a random national sample of US psychiatrists to assess attitudes, knowledge, and clinical experience regarding genetics. We hypothesized that clinicians with more recent genetics training would demonstrate more positive attitudes and greater genetics knowledge and experience than those with less recent training. METHODS:: A probability sample of US psychiatrists (n = 93) was invited to participate in a mail survey regarding genetic medicine. RESULTS:: Forty-five psychiatrists completed the survey (response rate = 48%). All believed that genetics strongly or moderately influenced a person's mental health. Respondents expressed positive attitudes toward incorporating genetics into psychiatric practice, but most did not have recent genetics training or experience in referring patients to genetic counselors or ordering genetic tests. Psychiatrists who had genetics training within the previous 5 years had more experience in providing genetic services. CONCLUSIONS:: This survey identified areas of strength (positive attitudes about providing genetic services, belief in the heritability of mental illness) and future targets for educational intervention (general genetics, information about testing and counseling resources). The association between recent training and a greater level of clinical genetics experience suggests that educational efforts may be successful in preparing psychiatrists to provide genetic services in the future.

Abstract

The personal health care issues of residents are important but have received minimal study. Available evidence suggests that residents experience difficulties obtaining care, partly related to both the demands of medical training and concerns about confidentiality and privacy.A self-report survey was distributed in 2000-2001 to advanced residents at the University of New Mexico Health Sciences Center. Questions related to personal health and health care attitudes, behaviors, preferences, and experiences, and vignettes related to personal illness and treatment. Here the authors report findings regarding preferences for obtaining health care "at" versus "outside" of one's training institution.Data from 141 residents are presented. A substantial minority of residents had obtained care outside of their institution in the preceding year. Residents expressed concerns about their medical privacy and confidentiality related to obtaining care within their own institution, including concerns about being seen by other residents or by past or future attendings. Women expressed more concern than did men on numerous issues, as did residents in primary care versus specialty training. Residents expressed a preference for care outside the training institution when taking into account confidentiality and prevention of embarrassment; care at their own institution was preferred when considering expense and scheduling. Outside care was more strongly preferred for more stigmatizing illnesses (e.g., mental health-related). Most residents felt poorly informed regarding their personal health care confidentiality rights and did not know whether their institution had confidentiality policies regarding residents who develop physical or mental health problems.Residents worry about confidentiality and privacy when deciding where to obtain personal medical care. Trainees' concerns are relevant to crafting policies on resident health care. Programs should strive to inform residents thoroughly about policies and rights pertaining to personal health care.

Abstract

Health care disparities are well documented for people living in rural areas and for people who are members of ethnic minorities.Our goal was to determine whether providers report greater difficulty in providing care for rural than urban residents and for ethnic minorities than patients/clients in general in 4 practice areas of ethical relevance: attaining treatment adherence, assuring confidentiality, establishing therapeutic alliance, and engaging in informed consent processes.We received survey responses from 1,558 multidisciplinary medical and behavioral providers across rural and non-rural areas of New Mexico and Alaska in 2004 to assess a wide range of issues in providing health care.Providers reported some difficulties in fulfilling various ethical practices for all types of patients, but not more difficulty when caring for minority compared to nonminority patients/clients. However, they do report more frequent additional problems related to the practice issues of treatment adherence, therapeutic alliance, informed consent, and confidentiality with minority patients than others. Difficulties and more frequent additional problems are greater for providers in rural than in non-rural areas. Results generalize across both Alaska and New Mexico with few differences.We obtained evidence for disparity in care for patients/ clients who were minority group members, and clear evidence of disparity for people residing in rural compared to non-rural areas of 2 states with large rural areas.

Abstract

Psychiatrists who practice psychosomatic medicine are routinely called upon to help resolve ethical dilemmas that arise in the care of patients near the end of their lives. Psychosomatic-medicine psychiatrists may be of unique value in these situations because of the clinical insights that we bring to the care of the dying patient. In particular, our subspecialty brings expertise related to the evaluation of decisional capacity of patients who are faced with accepting or declining end-of-life clinical interventions, such as resuscitation and intubation. In this first entry in a new bioethics case series in Psychosomatics, we will lay the groundwork for examining a complex patient case and provide an illustrative analysis of the end-of-life care issues that may be addressed by psychiatrists who practice psychosomatic medicine.

Abstract

Although it is commonly accepted that rural healthcare providers face demands that are both qualitatively and quantitatively different from those faced by urban providers, this conclusion is based largely on data from healthcare consumers and relies on qualitative work with small sample sizes, surveys with small sample sizes, theoretical reviews and anecdotal reports. To enhance our knowledge of the demands faced by rural healthcare providers and to gain the perspectives of healthcare providers themselves, this study explored the caseloads of rural providers compared with those of urban providers.An extensive survey of over 1500 licensed clinicians across eight physical and behavioural healthcare provider groups in Alaska and New Mexico was undertaken to explore differences in caseloads based on community size (small rural, rural, small urban, urban), state (Alaska, New Mexico) and discipline (health, behavioural).Findings indicated numerous caseload differences between community sizes that were consistent across both states, with complex case presentations being described most commonly by small rural and rural providers. Substance abuse, alcohol use, cultural diversity, economic disadvantage and age diversity were issues faced more often by providers in rural and small rural communities than by providers in small urban and urban communities. Rural, but not small rural, providers faced challenges around work with prisoners and individuals needing involuntary hospitalization. Although some state and discipline differences were noted, the most important findings were based on community size.The findings of this study have important implications for provider preparation and training, future research, tailored resource allocation, public health policy, and efforts to prevent 'burnout' of rural providers.

Abstract

This study attempted to clarify how people with schizophrenia evaluate the potential harm associated with various research-related procedures and how these assessments relate to participation willingness.The authors conducted a semistructured interview among participants with schizophrenia.Sixty participants with schizophrenia rated four procedures as harmful (e.g., symptom induction), five procedures as moderately harmful (e.g., being given a placebo), and six procedures as not harmful (e.g., undergoing a physical examination). Rated willingness to participate was inversely related to the participants' perceptions of harmfulness for all procedures.In this study, people living with schizophrenia perceived different research procedures as posing different levels of possible harm. Potential harm appears to be an important consideration in protocol enrollment decisions. This work reaffirms the value of clarifying the strengths of seriously ill people who may choose to participate in research.

Abstract

Schizophrenia studies involve diverse procedures with varying levels of risk. Federal regulations indicate that oversight of these protocols entails assessment of risk in relation to the risks encountered in everyday life. No data exist on comparing assessments of people with schizophrenia with those of psychiatrists regarding research procedure risks in relation to the usual risks of living with schizophrenia.Structured interviews were given to 43 people with schizophrenia and a parallel written survey was given to 68 psychiatrists to compare assessments of relative risk. Twelve research procedures were rated to compare the risk of the procedure with everyday risks. Possible scores range from 1, much less risk, to 3, about the same, to 5, much more risk.People with schizophrenia and psychiatrists viewed filling out questionnaires, drawing a tube of blood, drawing a tube of blood for a genetic test, and having X-rays of the head as being less risky than usual daily risks. Psychiatrists saw showing a word or picture that is upsetting as being less risky than usual daily risks. In contrast, patients saw having a spinal tap, getting a new experimental medication, getting a medication that causes temporary symptoms of schizophrenia, and stopping usual medications for two weeks as being significantly more risky than usual daily risks, but psychiatrists rated only stopping usual medications for two weeks as being more risky than usual daily risks.Substantial congruence exists between patients and psychiatrists regarding their views of research procedure risks. Further work is needed to determine how these assessments may be used in evaluating protocols.

Abstract

Prior research indicates survey procedures that signal significance and individualized mailings have higher response rates. Thus, it was hypothesized that surveys delivered via Priority mail would result in higher return rates than surveys delivered via First-Class. 260 surveys were sent to individuals randomly selected from lists of licensed physical and behavioral healthcare providers in Alaska and New Mexico. Half of the selected individuals were assigned randomly to receive mailings using Priority mail, the other half received First-Class mailings. Return rate was 39% for First-Class and 35% for Priority. Z tests of proportion indicated no statistically significant differences between methods. Given increased costs with no resultant increase in response rate, sending surveys to potential participants via Priority mail does not appear warranted.

Abstract

To identify the preferences of practicing licensed psychiatrists in two rural states regarding ethics training.All licensed psychiatrists in Alaska and New Mexico were mailed a survey exploring differences in ethical and practice issues between rural and urban health care providers. Data were collected from 97 psychiatrists.Findings indicated a moderate level of interest in training related to a diverse set of ethics topics. Although women expressed greater interest in most topics than did men, ranking of topics was similar across genders. Level of interest in training was inversely related to number of years in practice.The psychiatrists in this study indicated some interest in professionalism and ethics training, but did not express the level of need or enthusiasm documented in many studies of physicians-in-training. Creating continuing medical education initiatives that are attuned to the distinct needs and preferences of psychiatrists in clinical practice thus poses many challenges. This may be particularly true for certain aspects of practice, such as ethics and professionalism, that have long been recognized as vital to clinical care, but now are viewed as core competency areas.

Abstract

From an ethical perspective, psychiatrists cannot accept gifts of significant monetary value from their patients. This guideline raises important questions regarding institutional practices related to gift-giving in academic psychiatry. The first aim of this article is to explain the ethical tensions and shared ethical commitments of the professions of psychiatry and philanthropy. The second aim is to outline a series of steps that may be undertaken to assure ethical philanthropic practices within an institution, including the establishment of a committed advisory workgroup and the creation of ground rules and safeguards for gift-giving. Each situation should be evaluated for "ethical risk," and specific measures to safeguard donors should be considered.The author outlines methods to manage, minimize, or eliminate conflict of interest issues, including identification and disclosure of conflicting interests, role separation, goal clarification, confidentiality protections, proper timing, and ongoing oversight. Three case illustrations are provided and discussed.The process of institutional engagement, dialogue, and shared problem-solving is especially important. A shared, constructive ethic will be attained only if leaders and diverse stakeholders communicate the value of the new approach through their words, expectations, and actions.Through these efforts, greater attention will be given to the concerns of people with mental illness, and academic institutions may be better able to fulfill their responsibilities to this important but neglected population now and in the future.

Abstract

This report of the American Psychiatric Association's task force on research ethics addresses ethical issues related to the conduct of research involving human participants with mental illness. The report includes discussion of recruitment and ongoing participation of persons whose decisional capacity may be impaired and the ethical costs of categorically excluding persons with serious mental illness. Investigators should receive education in research ethics that addresses rules and norms governing research; sensitivity to ethical implications of decisions and actions; and skills in ethical problem solving, including ascertainment and disclosure of conflicts of interest. Ethical research design must ensure that a study has scientific merit, methods used should yield knowledge of value, and procedures must minimize risks to participants and optimize benefits. When risks are anticipated, plans should be developed to ensure participants' safety. The task force concludes with 12 recommendations for researchers, ethical review bodies, and advocacy groups to promote research and ensure ethical conduct of research.

Abstract

Ethical issues in research on serious physical and mental illnesses have received great attention, and yet little is known about how the perspectives of clinical research participants with different diagnoses may compare. We conducted a preliminary study to examine the attitudes of men enrolled in schizophrenia-related protocols and in HIV-related protocols regarding the importance of medical research, key aspects of research participation, and the acceptability of research involvement by various groups. A total of 33 men enrolled in schizophrenia protocols and 15 men enrolled in HIV-related protocols volunteered for our study. Respondents affirmed the importance of medical research and endorsed many positive things about participation. Autonomy and altruism were identified as motivators for research involvement. Participation by diverse groups was seen as acceptable. Respondents expressed comfort and little stress with the interview process. Men in different diagnostic groups largely saw the issues the same. Our findings thus suggest that people with schizophrenia and HIV/AIDS who are enrolled in protocols may share a number of core attitudes or beliefs related to ethical aspects of research participation. Further study is needed to explore how research involvement may influence perspectives and whether differences in views exist across people with diverse physical and mental illnesses.

Abstract

The research literature is replete with reports of barriers to care perceived by rural patients seeking healthcare. Less often reported are barriers perceived by the rural healthcare providers themselves. The current study is an extensive survey of over 1,500 healthcare providers randomly selected from two US states with large rural populations, Alaska and New Mexico. Barriers consistently identified across rural and urban regions by all healthcare professionals were Patient Complexity, Resource Limitations, Service Access, Training Constraints, and Patient Avoidance of Care. Findings confirmed that rural areas, however, struggle more with healthcare barriers than urban and small urban areas, especially as related to Resource Limitations, Confidentiality Limitations, Overlapping Roles, Provider Travel, Service Access, and Training Constraints. Almost consistently, the smaller a provider's practice community, the greater the reports of barriers, with the most severe barriers reported in small rural communities.

Abstract

Explored the relationship between different types of care providers' willingness to suggest alternative and complementary treatments (CAM), patients' requests for CAM, and provider perceptions about CAM as barriers to effective healthcare.Large survey.Alaska and New Mexico.Survey responses from 1528 physical and behavioral healthcare providers.Over 97% of providers suggested CAM; over 97% reported patients asked for CAM. Providers were more likely to suggest CAM than perceived CAM as a barrier to care. Healthcare providers who were female, from small rural areas, or specializing in behavioral healthcare were more likely to suggest CAM and less likely to perceive CAM as a barrier. Patients of physical healthcare providers asked for CAM more often than patients of behavioral healthcare providers, yet physical care providers suggested CAM less frequently.Healthcare providers of all disciplines, regions, and gender are sensitive to patients' desire for CAM and do not perceive CAM as a barrier to care.

Abstract

Serious mental illness research poses many ethical questions, including important considerations pertaining to how large a study is and its source of funding. Little is known about how people with schizophrenia understand these ethical considerations and whether these factors may influence their decisions to participate in research. Structured interviews were conducted with 60 people with schizophrenia. Participants were asked about levels of suffering and the importance of research for healthy people and for people with serious illnesses. Participants also rated helpfulness and harmfulness to society, and their likelihood of participating in studies involving 10 subjects, 1000 subjects, 1 research institution, or 10 research institutions and in studies funded by various organizations. Participants viewed all types of research positively and indicated willingness to volunteer. Likelihood of participating in research was correlated with perceived helpfulness to society and inversely correlated with perceived harmfulness. Research by pharmaceutical companies was seen as less helpful to society than research sponsored by federal or state government or by private foundations. Larger studies conducted at multiple sites were seen as more helpful to society than smaller studies or those at single sites. Larger studies conducted at single sites, however, were seen as more harmful. Respondents endorsed a positive view of medical research and expressed a willingness to participate in projects of all scales with diverse funding sources. The pattern of responses suggests the capacity for a nuanced understanding of ethically salient aspects of medical research by individuals with schizophrenia.

Abstract

Federal regulations governing human research suggest that potential harms and discomforts of research be considered in relation to the risks normally encountered in daily life or in routine examinations. No data regarding relative risks of research exist for persons with schizophrenia. We surveyed psychiatrists (N = 68) to assess their perceptions of the risk associated with 12 research procedures in 2 categories, that is, evaluation- and intervention-type procedures. Psychiatrists were asked to rate "risks compared to usual daily risks" for people with schizophrenia and, separately, for healthy people. For healthy research volunteers, psychiatrists rated 2 of 5 evaluation procedures and none of the intervention procedures as posing fewer risks than daily life. One evaluation procedure and 2 intervention procedures were rated as similar to daily risks for healthy research volunteers. For volunteers with schizophrenia, psychiatrists rated 4 of the 5 evaluation procedures and 1 intervention procedure as conferring less risk than everyday life. For 1 of 5 evaluation procedures and 5 of 7 intervention procedures, the risks associated with the procedures were centered close to the benchmark for those faced every day by persons with schizophrenia. Psychiatrists in this study viewed research procedure risks as closer to the daily risks encountered by persons with schizophrenia than by healthy persons. Because federal regulations benchmark research studies as "minimal risk" if they are analogous to the usual risks of everyday life, this finding may have important implications for the evaluation of psychiatric protocols.

Abstract

Many challenging ethical questions come with the scientific efforts to understand the nature and treatment of schizophrenia. The empirical study of ethical aspects of schizophrenia research has sought to clarify and resolve many of these questions. In this article we provide an overview of the existing data-based literature on schizophrenia research ethics and outline directions for future inquiry. We examine 5 broad categories of inquiry into the ethics of schizophrenia research: (1) Scientific designs (eg, placebo-controlled studies and medication-free intervals, prodromal and high-risk research, and genetics research); (2) informed consent and decision-making capacity, including assessment of decisional abilities, as well as intervention studies; (3) understanding and perceptions of risk and benefit (including the therapeutic misconception); (4) influences on research participation (including voluntarism, altruism, and other motivations); and (5) key participant safeguards, such as protocol review and participant advocates. We discuss how empirical work in each of these areas answers certain questions and raises new ones. Finally, we highlight important gaps in our understanding of ethically relevant aspects of schizophrenia research and offer a specific research agenda for empirical ethics.

Abstract

Investigators and institutional review boards are entrusted with ensuring the conduct of ethically sound human studies. Assessing ethical aspects of research protocols is a key skill in fulfilling this duty, yet no empirically validated method exists for preparing professionals to attain this skill.The authors performed a randomized controlled educational intervention, comparing a criteria-based learning method, a clinical-research- and experience-based learning method, and a control group. All 300 medical students enrolled at the University of New Mexico School of Medicine in 2001 were invited to participate. After a single half-hour educational session, a written posttest of ability to detect ethical problems in hypothetical protocol vignettes was administered. The authors analyzed responses to ten protocol vignettes that had been evaluated independently by experts. For each vignette, a global assessment of the perceived significance of ethical problems and the identification of specific ethical problems were evaluated.Eighty-three medical students (27%) volunteered: 50 (60%) were women and 55 (66%) were first- and second-year students. On global assessments, the criteria-focused group perceived ethical problems as more significant than did the other two groups (p < .02). Students in the criteria-focused group were better able than students in the control group (p < .03) to discern specific ethical problems, more closely resembling expert assessments. Unexpectedly, the group focused on clinical research participants identified fewer problems than did the control group (p < .05).The criteria-focused intervention produced enhanced ethical evaluation skills. This work supports the potential value of empirically derived methods for preparing professionals to discern ethical aspects of human studies.

Abstract

Physicians-in-training today are learning in an ethical environment that is unprecedented in its complexity. There is a call for new approaches in preparing medical students and residents for the ethical and professional issues they will encounter. The perspectives of physicians-in-training at different levels regarding the level of curricular attention needed for emerging bioethics concepts, practical informed consent considerations, and the care of special populations are unknown.The authors performed a hypothesis-driven, confidential survey study to assess perceived needs and preferences among medical students and residents related to medical ethics education at the University of New Mexico School of Medicine.A total of 336 physicians-in-training volunteered (62% response rate). Overall, strong interest was expressed for increased curricular attention to the domains of bioethics principles, informed consent, and care of special populations. Women students expressed greater interest generally. For certain domains, clinical students expressed relatively less curricular need and psychiatry and primary care residents expressed relatively greater curricular need. Two of the four hypotheses were supported, a third received partial support, and a fourth was not supported by the findings.To be valuable and effective, new ethics curricular approaches must be responsive to the current complex ethical environment and attentive to the preferences of medical students and residents of both genders, at different stages of training, with different patient care responsibilities. This hypothesis-driven study provides guidance for the inclusion of novel and important ethics domains in training curricula across medical school and diverse residency programs.

Ethical issues in the use of genetic information in the workplace: a review of recent developmentsCURRENT OPINION IN PSYCHIATRYGeppert, C. M., Roberts, L. W.2005; 18 (5): 518-524

Abstract

In the wake of the Human Genome Project, the pace of genetic discovery has quickened. New genetic tests and other molecular technology have had immediate and wide relevance to American and European workers. These tests have the potential to provide improved workplace safety and protect workers' health, but they also carry the risk of genetic discrimination including loss of employment, promotion, insurance and health care. Ethical safeguards are necessary if the benefits are to outweigh the adverse consequences of genetics in the workplace.This review examines the major policy statements issued in Europe and the USA from 2000 to 2005 pertaining to genetic issues in occupational health. Recent findings stress that genetic testing can only be utilized with worker consent and that the workers should control access to genetic information. Such testing is only justified when the information is required to protect the safety of the worker or a third party. The progress of occupational genetic technology should not be permitted to shift the responsibility for a safe working environment from the employer to the employee. Genetic discrimination in all forms is neither supported scientifically nor warranted ethically.Increasingly, occupational physicians and clinicians treating workers will be faced with potentially stigmatizing genetic information and there is an urgent need for education and research to expand and implement the recommendations of major governmental and professional policy statements.

Abstract

Ethics training has become a core component of medical student and resident education. Curricula have been developed without the benefit of data regarding the views of physicians-in-training on the need for ethics instruction that focuses on practical issues and professional development topics.A written survey was sent to all medical students and PGY1-3 residents at the University of New Mexico School of Medicine. The survey consisted of eight demographic questions and 124 content questions in 10 domains. Responses to a set of 24 items related to ethically important dilemmas, which may occur in the training period and subsequent professional practice, are reported. Items were each rated on a 9-point scale addressing the level of educational attention needed compared to the amount currently provided.Survey respondents included 200 medical students (65% response) and 136 residents (58% response). Trainees, regardless of level of training or clinical discipline, perceived a need for more academic attention directed at practical ethical and professional dilemmas present during training and the practice of medicine. Women expressed a desire for more education directed at both training-based and practice-based ethical dilemmas when compared to men. A simple progression of interest in ethics topics related to level of medical training was not found. Residents in diverse clinical specialties differed in perceived ethics educational needs. Psychiatry residents reported a need for enhanced education directed toward training-stage ethics problems.This study documents the importance placed on ethics education directed at practical real-world dilemmas and ethically important professional developmental issues by physicians-in-training. Academic medicine may be better able to fulfill its responsibilities in teaching ethics and professionalism and in serving its trainees by paying greater attention to these topics in undergraduate and graduate medical curricula.

Abstract

Physician impairment is defined by the presence of a physical, mental, or substance-related disorder that interferes with the ability to practice medicine competently and safely. The seeds of impairment may be sown early in adulthood, and medical students experience health issues that may receive insufficient attention in the context of a rigorous training period. Few empirical studies have examined the attitudes of medical students toward recognizing and acting upon signs of potentially impairing illnesses in peers.Medical students at 9 medical schools were invited to participate in a written survey exploring personal health care issues during training. As part of this larger project, students were asked to imagine their response in 3 situations to a medical student who is discovered to have serious symptoms and potential impairment secondary to mental illness, substance abuse, or diabetes.Responses were gathered from 955 students (52% overall response rate). For all of the vignettes, "tell no one but encourage him/her to seek professional help" was the most prevalent reaction (45%, 53%, and 49%, respectively) as opposed to seek advice (37%, 35%, and 42%) and notify the Dean's office (18%, 12%, and 9%). Willingness to report varied by school, and women were somewhat less likely to formally report medical student illness.This study suggests that medical students attach great importance to preserving the confidentiality of fellow medical students who may experience even very severe symptoms. This pattern may have important implications for the early recognition and treatment of potentially impairing disorders. Greater attention to these issues may help assure the health of early career physicians as well as the many patients whose safety and well-being are entrusted to their care.

Abstract

The societal use of genetic information raises ethical concerns, and the views of working persons regarding genetic information have received little attention. We performed an empirical project to characterize perspectives of 63 employees at two sites who expressed strong interest in learning about and protecting their personal genetic information. Genetic data were seen as more sensitive than other health data, and disclosure of genetic susceptibility was perceived as having negative consequences. This study suggests the value of exploring the perspectives of key stakeholders most directly affected by genetic applications across diverse societal settings.

Abstract

To examine the impact of financial compensation on pediatric asthma research participation decision-making and determine whether perceptions of fair compensation differed for parents and adolescents, lower and higher income participants, and compensation-informed and uninformed participants in minimal and above minimal risk research.Adolescents (n = 36) with asthma and their parents reviewed 7 pediatric asthma research protocols, decided whether they would choose to participate, and provided estimates of "fair" compensation for their participation. Chi-square, analysis of variance, and analysis of covariance were used to determine the affects of compensation on participation and whether various respondents differed in the perceptions of fair compensation.Financial compensation did not affect participation decisions. Estimates of fair compensation were lower for adolescents, lower income respondents, and participants who were naive about potential compensation. Fair compensation estimates were higher than actual compensation for minimal risk studies and lower for above minimal risk studies.Financial compensation may be a minor consideration in pediatric research participation decision-making. Still, differences in how pediatric researchers and their prospective participants judge fair compensation create the potential for undue influence. Pediatric researchers should use caution when determining a reasonable financial compensation for research participation.

Abstract

We review recent publications pertaining to six topics: investigators, professional integrity, and sources of potential bias; scientific designs; protocol safeguards; influences on research participation decisions and perceptions of risk; informed consent--decision-making capacity, appreciation and the therapeutic misconception, and voluntarism; and informed consent--intervention studies.Little empirical work has been conducted on investigator training and potential conflicts of interest. Numerous conceptual pieces have tackled controversial issues related to study designs, with the initial focal point being the ethics of placebo-controlled studies; only a handful of reports, however, have empirically addressed these topics. Emerging findings pertinent to protocol safeguards in schizophrenia research suggest general support by individuals with schizophrenia for a variety of safeguards. Recent work on influences on participation decisions suggests that people with schizophrenia use fundamentally similar considerations as medically ill people and healthy comparison participants--a combination of personal and altruistic motives. Much of the data-based literature has focused on informed consent. We highlight studies indicating that patients living with schizophrenia show heterogeneity in consent-related abilities but may possess key strengths in the research situation, not simply greater vulnerability as suggested in the historical literature. Furthermore, consent-related abilities appear to be enhanced with educational interventions.Empirical studies focusing on a variety of ethically relevant domains in schizophrenia research are needed. Future studies should incorporate quantitative and qualitative methods, integrate perspectives of stakeholders, and investigate the effects and appropriateness of current protocol safeguards.

Abstract

To investigate differences in the experiences of rural versus non-rural clinicians, we surveyed caregivers in New Mexico and Alaska regarding ethical aspects of care provision. Consistent with past literature, rural compared to non-rural clinicians perceived patients as having less access to health care resources. They reported more interaction with patients and less awkwardness in relationships with their patients outside of work. Rural clinicians also reported their patients expressed more concern about knowing them in both personal and professional roles, had more concerns over confidentiality, and experienced more embarrassment concerning stigmatizing illnesses. Ethical issues and implications of these results for providing care in rural areas are discussed.

Abstract

Insights from genetic research may greatly improve our understanding of physical and mental illnesses and assist in the prevention of disease. Early experience with genetic information suggests that it may lead to stigma, discrimination, and other psychosocial harms, however, and this may be particularly salient in some settings, such as the workplace. Despite the importance of these issues, little is known about how healthy adults, including workers, perceive and understand ethically important issues in genetic research pertaining to physical and mental illness.We developed, pilot tested, and administered a written survey and structured interview to 63 healthy working adults in 2 settings. For this paper, we analyzed a subset of items that assessed attitudes toward ethically relevant issues related to participation in genetic research on physical and mental illness, such as its perceived importance, its acceptability for various populations, and appropriate motivations for participation.Our respondents strongly endorsed the importance of physical and mental illness genetic research. They viewed participation as somewhat to very acceptable for all 12 special population groups we asked about, including persons with mental illness. They perceived more positives than negatives in genetic research participation, giving neutral responses regarding potential risks. They affirmed many motivations for participation to varying degrees. Men tended to affirm genetic research participation importance, acceptability, and motivations more strongly than women.Healthy working persons may be willing partners in genetic research related to physical and mental illnesses in coming years. This project suggests the feasibility and value of evidence-based ethics inquiry, although further study is necessary. Evidence regarding stakeholders' perspectives on ethically important issues in science may help in the development of research practices and policy.

Abstract

Several safeguards have been developed to protect research volunteers, but little is known about how the people involved in this research-the stakeholders-view these efforts to assure participant rights and well-being. The authors' goal was to examine these perspectives.As part of a larger study, 60 people with schizophrenia and 69 psychiatrists rated the protectiveness and influence on patients' willingness to participate in research of five safeguards: informed consent, alternative decision makers, institutional review boards, data safety monitoring boards, and confidentiality measures.All safeguards were perceived by both the participants with schizophrenia and by the psychiatrists as protective: on a scale of 1-5 on which 1=not protective at all and 5=very much protects, the mean scores ranged from 3.54 to 4.07. Four of the five safeguards were perceived by both the people with schizophrenia and by the psychiatrists as positively influencing patients' participation decisions. On a scale of 1-5 on which 1=much less willing and 5=much more willing to participate, the mean scores for these four safeguards ranged from 3.86 to 4.30. The mean score for the safeguard of an alternative decision maker, however, was 3.09. The ratings of protectiveness made by both the people with schizophrenia and the psychiatrists were correlated with their ratings of patients' willingness to participate in studies.Ethical commitment to research volunteers is expressed in safeguards. These efforts appear to be viewed positively by key stakeholders and may influence research participation decision making.

Abstract

To assess the perspectives and preferences of medical students and residents regarding professionalism and ethics education.A new written survey with 124 items (scale: "strongly disagree" = 1, "strongly agree" = 9) was sent to all medical students (n=308) and PGY 1-3 residents (n=233) at one academic center.Of the 336 participants (200 students, 65% response; 136 residents 58% response), only 18% found current professionalism and ethics preparation sufficient. Respondents endorsed professionalism (means=7.48 to 8.11) and ethics topics (means=6.56 to 6.87), women more so than men (p<0.05). Respondents preferred clinically- and expert-oriented learning over formal, nontraditional, or independent approaches (p<0.0001). They preferred clinically-oriented assessment methods (p<0.0001), residents more so than medical students (p<0.0001). On several items, psychiatry residents expressed greater receptiveness to professionalism and ethics preparation.Medical students and residents indicate support for professionalism and ethics educational initiatives, including diverse curricular topics and clinically-attuned assessments.

Abstract

volunteerism Mental illnesses are prevalent, cause great suffering, and are burdensome to society. Traditional "depot" antipsychotic agents are used to treat the most severely and persistently mentally ill individuals. They will soon be joined by new atypical antipsychotic medications in long-acting formulations. These long-acting medications pose special ethical issues, but may greatly benefit some people who suffer from severe and persistent mental illnesses. The objective of the current report is to highlight ethical considerations related to the use of long-acting antipsychotic medications. An analysis centering on the ethical concepts of voluntarism, beneficence, and justice is performed, integrating relevant empirical evidence and bioethics principles. Two main conceptual issues related to constraints upon voluntarism and coercion exist. Careful examination of ethically important empirical evidence suggests that voluntarism may not be perceived as an issue for some persons receiving depot antipsychotic medications. A favorable balance of benefits and risks has been documented for some individuals with severe and persistent mental illnesses. Access to care, innovative treatments, and long-acting antipsychotic medications may arise as an issue of justice and nondiscrimination in the care of mental illness. Considerations of justice indicate that long-acting medications may need to be used more frequently and earlier in the course of severe and persistent mental illness for select patients. We conclude that great care should be given to ethically important issues surrounding voluntarism, beneficent care, and equitable access to innovative psychiatric treatments, especially for persons who carry the burden of stigma as well as severe and persistent mental illness.

Abstract

To examine the perspectives and preferences regarding ethically important aspects of recruitment, consent, and debriefing of people with schizophrenia who volunteered for research protocols.A structured interview to assess research-related views of people with schizophrenia was developed and piloted. Data collection occurred at three sites. For this analysis, we examined the subset of responses from schizophrenia patients currently enrolled in a protocol.Data from 28 schizophrenia research volunteers were analyzed. Of these, 22 were men and 11 were voluntary inpatients. Most (n=23) recalled speaking with someone before enrolling in the protocol, and most (n=26) reported trusting the person who told them about it. Participants reported a moderate understanding of their protocols. All but one person (n=27) remembered signing a consent form. Twenty-one volunteers indicated that consent forms are meant to help both the patient and the researcher. Most (n=23) reported making the enrollment decision alone, with 22 making this decision prior to reviewing the consent form. The decision was described as relatively easy. Respondents felt some pressure to enroll, with women experiencing more pressure. Debriefing practices were strongly endorsed by participants. All 28 of the volunteers wished to be informed if a health problem (i.e., "something wrong") was discovered during the protocol.The persons living with schizophrenia who were interviewed for this project expressed interesting perspectives and preferences regarding ethically important aspects of recruitment, consent, and debriefing in clinical research that may help guide efforts to make research processes more attuned to participants and merit further inquiry.

Abstract

Study designs involving medication-free intervals have become the subject of controversy in the current dialogue on the ethics of serious mental-illness research.Schizophrenia patients ( n=59; response rate 75%; 48% inpatients) and psychiatrists ( n=70; response rate 83%) responded to ten questions about a hypothetical scenario in which a schizophrenia study participant experienced the re-emergence of serious symptoms during the "wash-out" phase of a psychopharmacological trial. Patients provided their personal views, and psychiatrists gave their personal views and made predictions as to how schizophrenia patients in general would respond.Schizophrenia patients and psychiatrists judged the hypothetical protocol as moderately harmful. Both expressed relatively low likelihood of willingness to participate in the study, given this potential outcome. Schizophrenia patients and psychiatrists found the decision fairly easy. Psychiatrists underestimated the level of harm and overestimated the difficulty of the decision as perceived by schizophrenia patients. Schizophrenia patients acknowledged that the offer of money and request by their doctor or family would increase the likelihood of their participation, and psychiatrists accurately predicted these responses. In hypothetical decisions about the symptomatic study participant, 38% of patients and 39% of psychiatrists said they would allow him to leave the hospital. A majority of both groups (63% and 52%, respectively) indicated that medication should be given despite the study participant's objection. Psychiatrists incorrectly predicted this response, expecting instead that most schizophrenia patients would support the discharge request and few would support involuntary administration of medication. Patients and psychiatrists offered similar reasons for participation decisions but differed in their strategies for handling the situation.These findings suggest potential strengths of decisionally capable schizophrenia patients in assessing ethically important design elements of psychopharmacological trials. Implications for informed consent for research, expectations of the therapeutic obligations of clinical investigators, and the role of psychiatric advance directives in psychopharmacological research are outlined.

Abstract

People living with addiction endure many hardships, and this may be especially true for women who face distinct clinical and significant psychologic and socioeconomic repercussions of addictive disorders and their companion stresses. Clinicians who work with women with addictions are confronted by many challenges, particularly in the care of pregnant and parenting women. The dilemmas faced by patients with addictions and their providers often arise directly from tensions among core ethical principles, from inconsistencies in the way these principles are applied, and from the pervasive effects of stigma. Although difficult issues are to be expected in the arena of substance abuse treatment, consideration of principles of voluntarism, beneficence, respect for persons and justice, confidentiality and truth-telling, and informed consent are invaluable in shaping clinical ethical decision making. Furthermore, proactive steps can be taken to enhance the ethical caliber of care. These steps involve policy-level and systemic actions, such as the development and expansion of programs serving women's unique needs, empiric research into the most effective treatments for women with various disorders, and reexamination of legal and societal stances toward pregnant and parenting women who have addictions. In addition, local and individual steps are needed, including addressing gaps or inherent biases in programs, training counselors and clinicians in effective strategies or counseling styles, and developing awareness of one's own attitudes when dealing with difficult patients and challenging disorders. Such efforts will help ensure that women who have addictions will be cared for in a manner that is respectful, beneficent, compassionate, honest, and just.

Abstract

Psychiatrists serve in different but important capacities with research participants. Because ethical problems may arise in research when participants misunderstand motives and responsibilities of clinical-investigators (i.e., "therapeutic misconception"), it is important that relationships between research participants and psychiatric caregivers and investigators be based on genuine mutual understanding. Considerations about attunement of psychiatrists with schizophrenia research participants have never been studied empirically. As part of a larger structured interview-survey study, we assessed the predictions of psychiatrists regarding self-reported experiences, attitudes, and motivations of individual schizophrenia research volunteers who were known to the respondent psychiatrists. Fourteen patient-psychiatrist pairs were identified for inclusion. Psychiatrists predicted schizophrenia research participants' ease of participation, privacy concerns, and willingness to participate in future research but underestimated their positive overall experience. Psychiatrists also were attuned to schizophrenia participants' attitudes and motivations regarding personal benefit but did not accurately predict their responses concerning helping others and science. Also, psychiatrists underestimated the schizophrenia participants' perceived degree of influence by researchers and caregivers during recruitment. Psychiatrists recognized the burden, primary concerns, future participation willingness, and personal benefit orientation of schizophrenia participants, but they did not appear to fully understand the overall positive quality of research experience, altruistic orientation, and relationship orientation of their schizophrenia patients who volunteer for research participation.

Abstract

To evaluate fourth-year medical students' abilities to obtain informed consent or refusal for HIV testing through a performance-based evaluation method.Student competence was assessed in a standardized patient interaction in which the student obtained informed consent or refusal for HIV testing. A previously validated 16-item checklist was completed by the standardized patient. A subset was independently reviewed and scored by a faculty member to calculate interrater reliability for this report. Student feedback on the assessment was elicited.School of Medicine at the University of New Mexico.All senior medical students in the class of 2000 were included.A 10-minute standardized patient interaction was administered within the context of a formal comprehensive performance assessment.Seventy-nine students participated, and most (96%) demonstrated competence on the station. For the 15 specific items, the mean score was 25.5 out of 30 possible points (range, 13 to 30; SD, 3.5) on the checklist. A strong positive correlation (rs =.79) was found between the total score on the 15 Likert-scaled items and the score in response to the global item, "I would return to this clinician" (mean, 3.5; SD, 1.0). Scores given by the standardized patients and the faculty rater were well correlated. The station was generally well received by students, many of whom were stimulated to pursue further learning.This method of assessing medical students' abilities to obtain informed consent or refusal for HIV testing can be translated to a variety of clinical settings. Such efforts may help in demonstrating competence in performing key ethics skills and may help ensure ethically sound clinical care for people at risk for HIV infection.

Abstract

The ethical caliber of psychiatric research ultimately rests upon the shoulders of psychiatric clinicians and investigators who perform protocols and are directly responsible for the welfare of study volunteers. Little is known, however, about ethically relevant attitudes of psychiatrists toward human research. Working as part of a larger study, we surveyed all psychiatry faculty and residents at one institution in 1999 regarding the relative importance of 12 elements in the ethical conduct of human research. Responses of 73 participants were analyzed, and three factors emerged: Safeguards and Scientific Merit, Investigator Integrity and Relationship, and Patient Benefit. Safeguards and Scientific Merit, as a set, were the most salient considerations for both psychiatry faculty and residents. We found that residents placed greater importance on all factors and nearly every element than did faculty. Future research is needed to clarify the understanding of the perspectives and priorities of different stakeholders involved in human studies.

Abstract

Schizophrenia affects more than 1% of the world's population, causing great personal suffering and socioeconomic burden. These costs associated with schizophrenia necessitate inquiry into the causes and treatment of the illness but generate ethical challenges related to the specific nature and deficits of the illness itself. In this article, we present a systematic analysis of narrative data from 63 people living with the illness of schizophrenia collected through semistructured interviews about their attitudes, beliefs, and experiences related to psychiatric research. In the comments of these individuals, half of whom had had prior personal experience in research protocols, we identified factors influencing openness toward research involvement as well as deterrents that appear to lessen interest in participation. Clear response pattern differences emerged between those with prior research experience and those without such experience. In the discussion, we explore the key findings and outline the implications for safeguards in mental illness research.

Abstract

Psychiatrists routinely encounter ethical complexities in caring for patients with mental illness, and they are held to the highest levels of accountability in their ethical practices. In this article, the authors first outline skills that are essential to ethical psychiatric practice. They then articulate three domains of clinical and ethical practice that represent the foundation of clinical care for people with mental illness: informed consent, the therapeutic relationship, and confidentiality. Key concepts concerning these domains are presented and relevant empirical evidence concerning each domain is reviewed. An understanding of these clinical and ethical practices will help psychiatrists serve patients with mental illness in their everyday clinical activities in a manner that is respectful, engenders trust, and ultimately fosters optimal clinical care.

Abstract

There are many tasks ahead in the area of ethics and mental illness research. We face unknown challenges in psychiatric genetics projects, studies of psychopharmacological interventions in children, controversial scientific designs (e.g., symptom challenge, medication-free interval), and cross-disciplinary research incorporating goals and methods of health services, epidemiology, and social and behavioral science endeavors. Boundaries between innovative clinical practices and research-related experimentation will become increasingly difficult to distinguish, as will the roles between clinicians, clinical researchers, and basic scientists. Moreover, the institutions and systems in which research occurs are being rapidly and radically revised, raising new questions about oversight responsibilities and standards. Our ability to identify and respond to the ethical questions arising in this uncharted territory will depend on our willingness to self-reflect, to integrate the observations and insights of the past century, to think with great clarity, and to anticipate novel ethical problems that keep company with scientific advancements. It will also depend on data. Empirical study of ethical dimensions of human research is essential to anchor and attune the intuitions and theoretical constructs that we develop. Science and ethics have changed over the past 100 years, as they will over the next century. It is ironic that the ethical acceptability of psychiatric research is so much in question at this time, when it holds so much promise for advancing our understanding of mental illness and its treatment. The tension between the duty to protect vulnerable individuals and the duty to perform human science will continue to grow, as long as ethics and science are seen as separable, opposing forces with different aims championed by different heroes. The profession of psychiatry is poised to move toward a new, more coherent research ethics paradigm in which scientific and ethical issues are recognized as inextricably linked: science as a human activity carries complex ethical meanings and responsibilities, and ethics itself is subject to scrutiny and amenable to scientific inquiry. Building a broader, more versatile, and more effective repertoire of safeguards will be increasingly important, and safeguards, in this view, represent a modest price for the privilege of studying serious illnesses--diseases that cause grave suffering and yet are a source of both vulnerability and strength. In this paradigm, attention to ethics safeguards is no longer understood as a barrier to scientific advancement, but rather as the means by which psychiatric research may be conducted with broad societal support, honorably and, ultimately, with the expectation of bringing benefit to millions of people with mental illness.

Abstract

Informed consent is built upon the elements of information, decisional capacity, and volunteerism. Of these elements, voluntarism in clinical and research consent is the least well understood. This has interfered with the ability to resolve key ethical problems faced by the field of psychiatry.The author suggests that voluntarism encompasses an individual's ability to act in accordance with one's authentic sense of what is good, right, and best in light of one's situation, values, and prior history. Voluntarism further entails the capacity to make this choice freely and in the absence of coercion. Deliberateness, purposefulness of intent, clarity, genuineness, and coherence with prior life decisions are implicitly emphasized in this construction.The author offers and illustrates a framework for voluntarism in clinical and research consent decisions, focusing on four domains of potential influence: 1) developmental factors, 2) illness-related considerations, 3) psychological issues and cultural and religious values, and 4) external features and pressures.It is hoped that improved understanding of voluntarism will help in our efforts to fulfill the principle of respect for persons in clinical care and research.

Abstract

A central ethical issue in schizophrenia research is whether participants are able to provide informed consent, particularly for protocols entailing medication washouts or placebo treatments. Few data show how patients with schizophrenia and psychiatrists assess such scientific designs regarding potential harm, willingness to participate, and the relative influence of clinicians, family members, and financial incentives upon participation decisions.In this preliminary study, structured interviews were conducted with schizophrenia patients (N=59), and parallel surveys were completed by attending and resident psychiatrists (N=70). Four hypothetical research protocols were rated. Patients were asked about their own views; psychiatrists provided both their personal views and predictions of patient views.Patients and psychiatrists both perceived substantially different levels of harm across the four protocols, identifying significantly greater harm for medication washouts or placebo treatments. Participants were less willing to enroll in protocols perceived as more harmful. Schizophrenia patients found enrollment decisions relatively easy. Patients and psychiatrists indicated that doctor recommendations, monetary incentives, and, to a lesser extent, family preferences had a mild influence on participation decisions.Given hypothetical protocols with variable design elements, schizophrenia patients and psychiatrists made meaningful and discerning harm assessments and participation decisions. These findings suggest that schizophrenia patients may have strengths in the research consent process that may not be fully recognized. The impact of outside influences upon research enrollment decisions remains uncertain. While psychiatrists were often accurate in predicting patient responses, data suggest the importance of clarifying views of individual patients regarding specific protocols.

Abstract

A consensus conference on the use of placebo in mood disorder studies consisted of expert presentations on bioethics, biostatistics, unipolar depression, and bipolar disorder. Work groups considered evidence and presented statements to the group. Although it was not possible to write a document for which there was complete agreement on all issues, the final document incorporated input from all authors. There was consensus that placebo has a definite role in mood disorder studies. Findings of equivalence between a new drug and standard treatment in active control studies is not evidence of efficacy unless the new drug is also significantly more effective than placebo. Add-on studies in which patients are randomized to standard therapy plus the investigational drug or standard therapy plus placebo are especially indicated for high-risk patients. Mood disorders in elderly and pediatric patients are understudied, and properly designed trials are urgently needed. Research is needed on the ethical conduct of studies to limit risks of medication-free intervals and facilitate poststudy treatment. Patients must fully understand the risks and lack of individualized treatment involved in research.

Abstract

Medical education research and medical education practice both involve being methodical, innovative, self-observing, forward-looking, and open to peer review, and both are scholarly activities. For these reasons, distinguishing between these two activities is often difficult. There are three important reasons to clarify the distinctions: the moral difference between education research and education practice; federal regulations governing education research that require more safeguards than often exist in education practice; and the fact that student participants in research have characteristics in common with members of special populations. The authors explain why attention to issues of safeguards in education research and practice is likely to grow at academic health centers, yet maintain that these issues are neglected in the medical education literature. They demonstrate this with findings from their review of 424 education research reports published in 1988 and 1989 and in 1998 and 1999 in two major medical education journals. Each article was evaluated for documentation of six ethically important safeguards and features (e.g., informed consent). The rates of reporting the six features and safeguards were relatively low (3-27%). Nearly half (47%) of the empirical reports offered no indication of ethically important safeguards or features, and no article mentioned all six. Furthermore, those rates did not increase substantially after ten years. The authors discuss a number of implications of their findings for faculty, training institutions, students, and editors and peer reviewers, and conclude with the hope that their findings will raise awareness of these neglected issues in medical education and will stimulate all those involved to reflect upon the issues and set standards on the ethical aspects of research and scholarly practice.

Abstract

The ethics of psychiatric research has emerged as a topic of national importance. Attention to this topic has been stimulated by a number of factors, including heightened awareness of the distinct moral problems arising in the care of mental illness, the rapid development of new psychopharmaceutical agents, the emergence of evidence-based approaches in psychiatry, the expansion of clinical trials within the private mental health sector, and recent recommendations offered by the President's National Bioethics Advisory Commission (NBAC). Consequently, clinical practitioners and investigators alike will increasingly be called upon to evaluate the ethical acceptability of psychiatric research protocols encountered in their professional work. In light of this, we present a framework for considering ethical aspects of psychiatric research protocols. This framework gives emphasis to nine elements: (1) scientific issues; (2) research team issues; (3) risk and benefit in protocol design; (4) confidentiality; (5) selection, exclusion, and recruitment considerations; (6) informed consent and decisional capacity; (7) incentives; (8) institutional and peer/professional review issues; and (9) data presentation issues. Case illustrations are provided. It is hoped that enhanced knowledge of the considerations presented in this framework will ultimately improve our ability to help people with mental illness.

Abstract

To explore medical students' views of assisted death practices in patient cases that describe different degrees and types of physical and mental suffering, an anonymous survey was administered to all students at one medical school. Respondents were asked about the acceptability of assisted death activities in five patient vignettes and withdrawal of life support in a sixth vignette. In the vignettes, actions were performed by four possible agents: the medical student personally; a referral physician; physicians in general; or non-physicians. Of 306 medical students, 166 (54%) participated. Respondents expressed opposition or uncertainty about assisted death practices in the five patient cases that illustrated severe forms of suffering which were secondary to amyotrophic lateral sclerosis, treatment-resistant depressive and somatoform disorders, antisocial and sexually violent behavior, or AIDS. Students supported the withdrawal of life support in the sixth vignette depicting exceptional futility secondary to AIDS. Students were especially opposed to their own involvement and to the participation of non-physicians in assisted death activities. Differences in views related to sex, religious beliefs, and personal philosophy were found. Medical students do not embrace assisted death practices, although they exhibit tolerance regarding the choices of medical colleagues. How these attributes of medical students will translate into future behaviors toward patients and peers remains uncertain. Medical educators must strive to understand the perspectives of physicians-in-training. Expanded, empirically informed education that is attuned to the attitudes of medical students may be helpful in fulfilling the responsibility of imparting optimal clinical care skills.

Abstract

The use of placebos in clinical trials, particularly in research with mentally ill people, has emerged as a subject of considerable controversy. We first outline ethical aspects of the primary scientific arguments for and against placebo use in research. Three examples of paradoxical aspects of the ethical use of placebos are discussed: involvement of relatively more vulnerable populations, use of apparently "less than standard" therapy, and the omission of information in placebo comparisons. In the current scientific and regulatory context, placebo use in psychiatric research may be necessary for scientific reasons, and when certain conditions are present, it may be justified on ethical grounds. Four key recommendations to facilitate the ethical use of placebos in research trials are presented. We conclude that placebo trials should be undertaken only after careful evaluation of alternative scientific strategies and, as with all human research, with great respect and genuine consideration for the individuals who choose to participate in these protocols.

Abstract

About one quarter of the more than 69,000 medical students in this country suffer symptoms of mental illness, including 7% to 18% with substance use disorders. Subjective distress and physical health needs of medical students are also common and have been linked to training stresses. This first large-scale study of medical student health care examined students' physical and mental health concerns and their perceptions of academic vulnerability associated with personal illness. A 7-page, confidential written survey was given to 1,964 students at nine US medical schools in 1996 and 1997. A total of 1,027 students participated (52% response rate). Nearly all (90%) reported needing care for various health concerns, including 47% having at least one mental health or substance-related health issue. A majority of students expressed a preference for health care outside their training institution, largely due to confidentiality concerns, and 90% preferred health insurance allowing off-site care. Students expressed varying levels of concern about academic jeopardy in association with personal illness, with physical health problems such as arthritis causing the least concern and alcohol and drug abuse triggering the most concern. Consistent differences were detected in these views based on respondent's gender, training level, and institution. Most medical students perceive the need for personal health care. Nevertheless, fear of academic reprisal may prevent medical students from seeking necessary care for their health problems during training. This phenomenon may be linked in important but poorly recognized ways to emerging illness and to impairment among medical students and physicians. Women, minority, and clinical students appear more sensitive to the connection between health and academic vulnerability. Constructive implications for medical school curricula, policies, and health care services are discussed.

Abstract

Forensic pathologists face difficult moral questions in their practices each day. Consistent ethical and legal guidelines for autopsy tissue use extending beyond usual clinical and legal imperatives have not been developed in this country.To obtain the perceptions of medical examiners regarding the ethical acceptability of autopsy tissue use for research and education.A written, self-report questionnaire was developed and piloted by a multidisciplinary team at the University of New Mexico, Albuquerque. All individuals who attended a platform presentation at the National Association of Medical Examiners Annual Meeting in September 1997 were invited to participate.Ninety-one individuals completed the survey (40% of all conference registrants and approximately 75% of presentation attendees). Sixty-three percent of respondents had encountered an ethical dilemma surrounding autopsy tissue use, and one third reported some professional ethics experience. Perspectives varied greatly concerning the ethical acceptability of using autopsy tissues to demonstrate or practice techniques (eg, intubation, brachial plexus dissection) and of fulfilling requests to supply varying kinds and quantities of tissues for research and education. Most respondents indicated that consent by family members was important in tissue use decisions. Respondents agreed on the importance of basic values in education and research, such as integrity, scientific or educational merit, and formal institutional approval of a project. Characteristics of the decedent did not influence decisions to release tissues, except when the individual had died from a mysterious or very rare illness. Attributes of medical examiners, with the exception of sex, also did not consistently predict responses.Significant diversity exists in beliefs among medical examiners regarding perceptions of the appropriate use of autopsy tissues for education and research. There is need for further inquiry and dialogue so that enduring policy solutions regarding human tissue use for education and research may be developed.

Abstract

The mental and physical health care issues of medical students are increasingly recognized as both prevalent and complex. Emotional distress, symptoms of mental illness, and maladaptive substance use are widespread and may often be driven by training-related stressors. The data suggest that nearly all medical students identify physical health concerns as well. The care of medical students as patients is complex because of problems associated with the stigma of various illnesses and the dual role of trainee and patient in medical school. A written confidential survey assessed students longitudinally near the end of their first and third years of training regarding their perceived health care needs, health concerns, attitudes toward care, access to services, and care-seeking practices (161 items). A subset of students (n = 33) were reassessed 1 month after the second survey to measure reliability. McNemar's chi-square (chi2) tests, repeated-measures multivariate analysis of variance (MANOVA), and K and Pearson correlations were used to evaluate outcomes. Almost all students reported health care needs during both training phases, and their mental and physical health concerns were stable over time. However, the preference for obtaining health care at a site other than their training institution and concerns about confidentiality increased, although students were marginally more likely to obtain care at their medical school during clinical versus preclinical training. The students' tendency to seek informal care from colleagues remained consistent, as did their high level of concern about professional jeopardy relating to personal health issues. Their tendency to accept the dual patient-student role depended on the particular health care issue; they expressed a strong tendency to protect other students' confidentiality, even in cases of potential significant impairment. Responses were reliable across a 1-month retest interval. We conclude that medical students' perspectives on their mental and physical health care across the transition from preclinical to clinical training reveal the importance of pursuing, not neglecting, a number of clinical and educational initiatives. Through their specialized expertise, psychiatrists may help to ensure sound mental and physical health care for the more than 69,000 medical students in training in this country.

Abstract

The personal health care of medical students is an important but neglected issue in medical education. Preliminary work suggests that medical student-patients experience special barriers to health care services and report problematic care-seeking practices that merit further inquiry.A self-report questionnaire was piloted, revised, and distributed to students at nine medical schools in 1996-97. The survey included questions regarding access to health services, care-seeking practices, and demographic information.A total of 1,027 students participated (52% response rate). Ninety percent reported needing care for various health concerns. Fifty-seven percent did not seek care at times, in part due to training demands, and 48% had encountered difficulties in obtaining care. A majority had received treatment at their training institutions, and students commonly pursued informal or "curbside" care from medical colleagues. Almost all participants (96%) were insured. Differences in responses were associated with level of training, gender, and medical school.Medical schools shoulder the responsibility not only of educating but also of providing health services for their students. Students encounter barriers to care and engage in problematic care-seeking practices. Greater attention to issues surrounding medical student health may benefit students and their future patients.

Abstract

Significant controversy surrounds the ethics of psychiatric research. Nevertheless, few data have been gathered to improve our understanding of how individuals with serious mental illness and psychiatrists view ethically important aspects of biomedical research participation.The authors assessed views of clinically diagnosed patients with schizophrenia from three sites by means of structured interviews and views of psychiatrists at two sites with written surveys regarding attitudes affecting motivation to participate in biomedical research, attitudes related to autonomy and influences on participation decisions, and attitudes toward the inclusion of vulnerable populations in research. The schizophrenia patients were asked to indicate their personal views; the psychiatrists were asked to provide their personal views and to predict schizophrenia patients' views. Responses were compared by using repeated measures multivariate analysis of variance.Sixty-three patients with schizophrenia and 73 psychiatry faculty and residents participated. Overall, responses to 23 rated attitudes revealed remarkably similar rank orders and several areas of agreement between patients and psychiatrists. Both groups strongly supported schizophrenia research and autonomous decision making by participants. They saw helping others and helping science as important reasons for protocol participation. Patients endorsed the feeling of hope associated with research involvement, a perspective underestimated by psychiatrists. Psychiatrists also underestimated the patients' acceptance of physician, investigator, and family influences on participation decisions. Psychiatrists agreed more strongly than patients that vulnerable populations should be included in research.This study helps to characterize previously neglected attitudes of psychiatric patients and clinicians toward ethically important aspects of biomedical research participation. Schizophrenia patients offered highly discerning views, and interesting similarities and differences emerged in comparing responses of patients and psychiatrists.

Psychiatric research ethics: An overview of evolving guidelines and current ethical dilemmas in the study of mental illnessBIOLOGICAL PSYCHIATRYRoberts, L. W., Roberts, B.1999; 46 (8): 1025-1038

Abstract

The field of psychiatry has an opportunity to construct a more refined, perhaps more enduring understanding of the ethical basis of mental illness research. The aim of this paper is to help advance this understanding by 1) tracing the evolution of the emerging ethic for biomedical experimentation, including recent recommendations of the President's National Bioethics Advisory Commission, and 2) reviewing data and concepts related to compelling ethical questions now faced in the study of mental disorders. Empirical findings on informed consent, the ethical safeguards of institutional review and surrogate decision making, and the relationship between scientific and ethical imperatives are outlined. Psychiatric researchers will increasingly be called upon to justify their scientific approaches and to seek ways of safeguarding the well-being of people with mental illness who participate in experiments. Most importantly, psychiatric investigators will need to demonstrate their appreciation and respect for ethical dimensions of investigation with special populations. Further empirical study and greater sophistication with respect to the distinct ethical issues in psychiatric research are needed. Although such measures present many challenges, they should not interfere with progress in neuropsychiatric science so long as researchers in our field seek to guide the process of reflection and implementation.

Abstract

Preparing experimental protocols that are ethically sound, possess scientific merit, and meet institutional and national standards for human subject protections is a key responsibility of psychiatric investigators. This task has become increasingly complex due to developments in biomedical science, bioethics, and society at large. Practical and constructive approaches to help investigators in their efforts to create protocols that are ethically acceptable have nevertheless received little attention. To better address this gap, the Research Protocol Ethics Assessment Tool (RePEAT) was developed as an educational instrument to help assure that ethically important elements, including scientific design features, are explicitly addressed by investigators in their work with protocols involving human participants. The RePEAT is a brief evaluative checklist that reflects rigorous ethical standards, particularly with respect to criteria for studies that may involve individuals with compromised decisional abilities. For this reason, it may be especially beneficial as a self-assessment tool for investigators and protocol reviewers in psychiatry. To stimulate education and dialogue, this report presents the RePEAT and outlines its content, format, use, and limitations.

Abstract

Medical schools increasingly place emphasis on preparing students to perform routine, ethically important clinical activities with sensitivity and acumen. A method for evaluating students' skills in obtaining informed consent that was created at our institution is described.Formal assessment of medical students' professional attitudes, values, and ethics skills occurs in the context of three required and developmentally attuned comprehensive examinations. A videotaped station tested senior medical students' ability to obtain informed consent from a standardized patient who expresses concern about undergoing cardiac catheterization. Two checklists were completed by the patient. Videotapes were reviewed by a faculty member, and students' reactions to the assessment experience were documented.Seventy-one senior students participated, and all performed well. Mean scores of 6.3 out of 7 (range 5 to 7, SD = 0.5) on the informed consent checklist and 8.7 out of 9 (range 6 to 9, SD = 0.5) on the communication skills checklist were obtained. Students endorsed the importance of the skills tested.This method of examining medical students' abilities to obtain informed consent has several positive features and holds promise as an ethics competence assessment tool.

Abstract

The study objective was to clarify the ethical basis of psychiatric research by outlining conceptual issues and empirical findings related to the ethics of human experimentation. A systematic review of scholarly and empirical literature covering three decades was performed. The ethics of human research has come to be understood in relation to the principles of respect for persons, beneficence, justice, and the ideal of informed consent. Subjects who cannot fully participate in informed-consent processes are especially vulnerable to exploitation. Current dilemmas stem from insufficient attention to the vulnerabilities of mentally ill research participants, problems in applying ethical concepts and guidelines to psychiatric research, and claims of research misconduct. Empirical studies indicate that (1) psychiatric symptoms significantly affect informed consent, (2) psychiatric patients may possess certain strengths with respect to research involvement, (3) proxy decision-making is problematic, (4) informed consent is also difficult to attain with the medically ill and others, (5) patients are motivated to participate in research by the hope of personal benefit, (6) ethical aspects of research are poorly documented, and (7) institutional review processes may not be adequate to protect vulnerable subjects. Psychiatric research can be performed ethically, according to standards set throughout the biomedical and behavioral sciences, so long as researchers and institutions are respectful of special ethical issues in human experimentation and strive to include vulnerable study participants fully in research decisions. However, many gaps in the empirical literature exist regarding the specific nature and implementation of ethics principles in psychiatric research. Efforts to advance both science and ethics, including the study of ethical dimensions of human research itself, are essential for the future of psychiatry.

Abstract

Controversy has arisen in recent years about the participation of psychiatric patients in questionably ethical research protocols. Consequently, academic psychiatrists have been called upon to enrich their understanding of the ethical aspects of research and to teach residents more intensively about these issues in scientific methodology. Toward these ends, the authors have assembled an extensive resource listing in the area of psychiatric research ethics. Articles were identified through MEDLINE and BIOETHICS LINE computerized searches and the authors' review of relevant literature through 1996. Emphasis was placed on those pieces with special historical value, empirical studies, and papers that provide background on the current controversies in psychiatric research ethics. The references were organized into five logical categories. Based on the resource review, the authors briefly discuss areas related to research ethics that merit greater attention in academic psychiatry.

Abstract

The objective of this study was to investigate the views of consultation-liaison (C-L) psychiatrists on assisted-death practices. A 33-question anonymous survey was distributed at the Academy of Psychosomatic Medicine Annual Meeting in November 1995. The instrument explored perceptions of acceptability of assisted death in six hypothetical patient situations as performed by four possible agents. The response rate was 48% (184 conference attendees participated, i.e., completed and returned the surveys). With little variability, the respondents were unwilling to perform assisted death personally and also did not support assisted death as performed by nonphysicians. The respondents were somewhat more accepting of referral or other physicians' involvement in such practices. Assisted death was viewed differently than withdrawal of life support. Several variables were analyzed for their influences on the views expressed. The C-L psychiatrists in this study expressed opposition to assisted death practices. Their views varied somewhat depending on the patient vignette and the agent of death assistance. The authors conclude that C-L psychiatrists may wish to develop their present therapeutic and evaluative role in patient care to alleviate suffering, without hastening patient death.

Abstract

Although studies have revealed conflicting attitudes within the medical community regarding assisted death practices in the United States, the views of current resident physicians have not been described.To investigate the perspectives of residents from 3 medical specialty fields regarding the acceptability of assisted suicide and euthanasia practices as performed by 4 possible agents (the resident personally, a referral physician, physicians in general, or nonphysicians in general) in 6 patient scenarios.An anonymous survey exploring responses to 6 patient vignettes was conducted with a convenience sample of all residents in the internal medicine, psychiatry, and emergency medicine training programs.A total of 96 residents, 72% of those asked, participated in this study. Overall, residents expressed opposition or uncertainty regarding assisted suicide and euthanasia. The residents were disinclined to directly perform such practices themselves and did not support the conduct of assisted suicide practices by nonphysicians. Respondents were somewhat more accepting of other physicians' involvement in assisted death activities. Conflicting views were expressed by residents, with emergency medicine residents more likely to support assisted suicide practices in 4 of 6 patient vignettes than either internal medicine or psychiatry residents. Residents who reported being influenced by religious beliefs (21 respondents [22%]) did not support assisted death practices, whereas those influenced by personal philosophy (74 respondents [77%]) expressed less opposition.This study explores the uncertainty and differing views of residents from 3 fields about physician-assisted suicide practices. Study findings are considered within the larger literature on clinician attitudes toward assisted suicide and euthanasia.

Abstract

The personal health experiences of medical students may contribute in important but previously unacknowledged ways to their well-being and education. This pilot study surveyed medical students about their health care needs, practices, insurance status, and concerns about seeking care.A questionnaire was developed and distributed to 151 students at the University of New Mexico School of Medicine in 1993-94. Participant privacy was protected. Responses were compiled and analyzed using logistic regression models and odds ratios.A total of 112 students responded. Most reported health care needs and half routinely received care at their training institution. One-third had informally requested prescriptions or diagnostic tests from medical school faculty and housestaff; one-fourth used such informal consultation as their "usual" method of obtaining care. Eighteen students were uninsured. The students reported that they had not sought care for several reasons, and many had experienced difficulty in obtaining care. The students indicated concern about confidentiality and about the dual role as both student and patient at the training institution. They believed that their academic standing would be jeopardized if they developed certain health problems. When asked about hypothetical scenarios, a majority preferred to avoid the dual role of medical-student-patient. When asked about scenarios in which medical student peers exhibited suicidal depression or severe drug abuse, the students overwhelmingly preferred not to notify the medical school administration. Significant differences in responses were found with respect to gender and training level.This pilot study examined the health care needs, practices (including the use of informal consultation), insurance status, and concerns of students at one medical school. The findings highlight the students' perceptions of illness and vulnerability during medical school training. Constructive implications for academic medicine are discussed regarding initiatives in the areas of policy, research, and the resources and structure of student health care services.

Abstract

The study's objective was to survey what and how psychiatry residents want to learn about ethics during residency. A 4-page questionnaire developed for this study was sent to 305 residents at 10 adult psychiatry programs in the United States. One-hundred and eighty-one (59%) of those surveyed responded. Seventy-six percent reported facing an ethical dilemma in residency for which they felt unprepared. Forty-six percent reported having received no ethics training during residency. More than 50% of the respondents requested that "more" curricular attention be paid to 19 specific ethics topics and more than 40% for 25 topics. Preferences with respect to learning methods are presented. This survey may provide guidance in structuring the content and process of ethics education for psychiatry residents. These findings should stimulate the efforts of faculty to commit time and attention to this important curricular area.

Abstract

Supervision of psychiatric residents provides a natural context for clinical ethics teaching. In this article, the authors discuss the need for ethics education in psychiatry residencies and describe how the special attributes of supervision allow for optimal ethics training for psychiatry residents in their everyday encounters with ethical problems. Ethical decision making in clinical settings is briefly reviewed, and a 6-step strategy for clinical ethics training in psychiatric supervision is outlined. The value of the clinical ethics supervisory strategy for teaching and patient care is illustrated through four case examples.

Abstract

Providing urologic care to men who have been traumatized during childhood may be especially challenging because of the extent, severity, and unusual character of their urogenital problems. Recognition of past trauma entails attentiveness to patients' background and behaviors. As illustrated through these 15 cases, patients who present with too many past surgeries, too many unremitting urologic complaints, too little sexual function and too few genital parts, sexual impulses that are too strong, sexualized conduct in clinical settings, and self-destructive behaviors surrounding sexuality may have experienced trauma in the past. While empirical studies are necessary to demonstrate the ultimate utility of these categories, appreciation of these clinical indications improves the urologic care provided to traumatized men in four ways: by elucidating unusual and unusually recalcitrant urologic complaints, thereby clarifying clinical decisions; by allowing for appropriate use of psychiatric consultation; by promoting a better understanding of the sequelae of trauma in men; and by alleviating the discomfort naturally felt by urologists and their staff when caring for these difficult, multiproblem patients.

Abstract

Medical ethics education is instruction that endeavors to teach the examination of the role of values in the doctor's relationship with patients, colleagues, and society. It is one front of a broad curricular effort to develop physicians' values, social perspectives, and interpersonal skills for the practice of medicine. The authors define medical ethics education as more clinically centered than human values education and more inclusive of philosophical, social, and legal issues than is interpersonal skills training. The authors review the history of the emergence of medical ethics education over the last 20 years, examine the areas of consensus that have emerged concerning the general objectives and premises for designing medical ethics programs, and describe teaching objectives and methods, course content, and program evaluation used in such programs on both preclinical and clinical levels. The four interrelated requirements for successful institutionalization of medical ethics education programs are defined and discussed, and the paper ends with an overview of the uncertain future of medical ethics education, an accepted but still not fully mature part of physician training in the United States. An extensive reference list accompanies the article.

DEVELOPMENT OF A TEACHING PROGRAM IN CLINICAL MEDICAL-ETHICS AT THE UNIVERSITY-OF-CHICAGOACADEMIC MEDICINEWalker, R. M., LANE, L. W., Siegler, M.1989; 64 (12): 723-729

Abstract

The University of Chicago Pritzker School of Medicine has developed and evaluated an extensive teaching program in clinical ethics coordinated primarily through the Center for Clinical Medical Ethics. The program provides medical students with a foundation in medical ethics during the four years of medical school and augments the clinical ethics knowledge and teaching skills of the housestaff and clinical faculty at the University of Chicago. Together, medical student teaching and clinical faculty development have made clinical ethics an integral part of medical education at the University of Chicago. Through these efforts, the teaching program aims to incorporate clinical ethics considerations into medical decisions and in this way contribute to improving patient care. (A detailed overview of all clinical ethics instruction at the school is provided.)

Abstract

Evolutionary hypotheses have been used widely to interpret enigmatic psychiatric phenomena. In applying evolutionary theory, three common methodological errors occur: imprecise and inappropriate use of evidence and theoretical concepts; incorrect assessment of the level at which evolutionary processes occur; and potential misinterpretation of observations due to a confusion of proximate and ultimate causation. Guidelines and criteria for developing meaningful evolutionary hypotheses and rigorous research strategies are described. It is hoped that these efforts will enhance the contribution evolutionary theory may have as it is applied to psychiatric observations in the future.